Discharge from hospital
15. Ms D says doctors discharged her mother on 23 March 2020 despite the fact she had respiratory failure and low oxygen levels. She says this led to her mother needing to return to hospital three weeks later. She also felt clinicians did not provide her mother with enough support. Ms D says doctors had still not found a cause for her mother’s problems on 17 April 2020 yet they discharged her again with worsening respiratory failure.
16. The Medical Adviser told us there were specific guidelines in place for hospitals during the COVID-19 pandemic. These were set out in the Discharge Guidance. This explained that clinicians should have arranged a basic assessment of function for patients they were considering for discharge. This related to transfers and mobility. The Discharge Guideline said when clinicians no longer considered patients to be ‘acutely unwell’ they should have sent them home.
17. The Discharge Guidance said that if a patient could not manage at home without assistance clinicians should arrange health and or social care support. If this was not suitable then they should consider a rehabilitation bed. If the admission had been so life-changing that the patient could not leave hospital with any support clinicians should ensure they continue to stay in hospital. The Guidance suggested around one per cent of patients would remain in hospital.
18. The Home Oxygen Guideline provides guidance for the use of oxygen for patients who are not in hospital. It says home oxygen is not needed in cases of neuromuscular weakness unless oxygen saturation levels are too low despite non-invasive ventilation.
19. The clinical records show that on 19 March 2020 Mrs D could mobilise using a frame and only needed supervision. Ms D said she was happy to provide all care. On 23 March clinicians noted Mrs D needed only minimal assistance with personal care and was independently mobile with her frame, meaning she did not need help when moving. Equipment had been provided to support Mrs D at home and Ms D confirmed this was in place before the discharge.
20. The Medical Adviser noted Mrs D’s oxygen saturation levels had been between 95 and 98 percent for several days. This is an acceptable level and would not have been considered an issue unless it fell considerably lower, most likely below 90 percent in Mrs D’s case. At this point doctors did not consider Mrs D needed non-invasive ventilation. They made this decision after an appropriate level of consideration and with specialist consultation. There is no suggestion this was inappropriate advice.
21. The evidence shows there was no reason for Mrs D to remain in hospital on 23 March 2020. There was no concern about her oxygen saturation levels and there was an appropriate assessment of her needs after the discharge. We find clinicians followed the Discharge Guidance.
22. The clinical records from 14 April 2020 show Mrs D was mobile with her frame and the assistance of one person. She needed regular assistance with position changes to prevent pressure ulcers and needed help with her hygiene needs. The next day she had improved to being independent with position changes and only needed help when washing and dressing. Ms D had been assisting her mother with activities of daily living and was happy to continue to do so following discharge.
23. A physiotherapist assessed Mrs D on 17 April 2020. They considered it was safe for doctors to discharge her. By this stage Mrs D was using non-invasive ventilation. The Medical Adviser told us appropriate arrangements were made to follow this up, including showing Ms D how to use the equipment.
24. Mrs D’s oxygen saturation level had been between 92 percent and 95 percent for several days. This was lower than during her previous hospital admission. The Medical Adviser said this was acceptable and oxygen support would not have been needed unless this fell considerably lower. Doctors followed the Home Oxygen Guideline in not providing Mrs D with home oxygen on discharge.
25. We find doctors followed the Discharge Guidance and the Home Oxygen Guideline when they discharged Mrs D from hospital on 23 March and 17 April 2020. We recognise Ms D strongly believes there were failings in this respect. On both occasions there was no suggestion Mrs D was acutely unwell and needed to remain in hospital. We hope Ms D is reassured we have seen no evidence the doctors fell below the required standards.
Pressure area care
26. Ms D says her mother developed pressure ulcers during her admission to the Freeman Hospital. She says this was not highlighted in the discharge letter from the hospital and so the pressure ulcers got worse and were not treated.
27. The Pressure Ulcer Guideline says clinicians should carry out and document an assessment of pressure ulcer risk for all patients admitted to hospital. They should reassess the risk when there is a significant change in clinical status.
28. The Pressure Ulcer Guideline says clinicians should offer an individualised care plan to those at high risk of developing a pressure ulcer. They should also offer those patients a skin assessment and encourage them to change their position frequently and a least every four hours. They should also offer such patients a specialised foam mattress and consider using a barrier cream.
29. The clinical records show nurses assessed Mrs D’s pressure area risk three times during her first admission to the Hospital. The first of these was on 18 February 2020. A nurse identified Mrs D was at risk of pressure area damage.
30. Nurses planned to ensure Mrs D’s position changed every two hours. They recorded her lower back was red from her long wait after the fall and they applied a cream to try and prevent further damage. Records show nurses repositioned Mrs D every two hours during her hospital stay. They also gave her a pressure relieving mattress and cushion. However, we can see no evidence of an individualised care plan being in place relating to pressure area care.
31. The area around Mrs D’s lower back was vulnerable throughout the admissions we have investigated. On 23 February 2020 a nurse recorded there was a grade one pressure ulcer. This was a red area over a bony prominence and the skin was not broken. By 25 February a nurse observed this had resolved with no redness or broken skin. But the problem returned again on 29 February.
32. A tissue viability nurse reviewed Mrs D on 4 March 2020. They confirmed Mrs D had a moisture lesion on her lower back or left buttock. Nurses continued to treat this with a barrier cream. On 19 March a nurse noted Mrs D’s lower back was ‘very red but blanching,’ meaning the area lightened when pressed.
33. The majority of the clinical records from 23 March 2020 do not make any reference to pressure ulcers. Nurses noted there was evidence of healed ulcers and Mrs D’s skin was fragile. This was contradicted by a discharge form which suggested Mrs D had a grade two pressure ulcer. A grade two ulcer means the ulcer had broken through the top layer of the skin and part of the layer below. There is no other clinical evidence to suggest a grade two pressure ulcer was present at that stage based on the records that we have seen. The discharge letter to the GP did not refer to a pressure ulcer. We cannot explain this contradiction.
34. We have seen limited documentation about pressure area care following Mrs D’s readmission. A nurse reviewed her on 12 April 2020. They noted she had a grade two pressure ulcer on her lower back. The next day a nurse observed Mrs D’s skin was extremely fragile but was blanching. They applied cream and noted that regular repositioning was taking place. They noted her skin was close to breaking down but was intact.
35. On 14 April 2020 a nurse noted Mrs D was using a pressure-relieving cushion. They documented that part of her lower back was red with a small area that was not blanching. They administered barrier cream and gave assistance with a positional change.
36. The Nursing Adviser told us there were few documents relating to checking the skin around Mrs D’s lower back from 14 March 2020 onwards. This means it is difficult to establish whether Mrs D did have a grade two pressure ulcer at the time of her discharge from hospital on 23 March. We can see evidence that nurses attempted to reposition Mrs D every two hours. We can also see that nurses selected ‘yes’ when prompted about whether they checked pressure areas. But there is no detail about these checks.
37. There is no evidence of nurses assessing Mrs D’s pressure area risk after she returned to the Royal Victoria Infirmary on 12 April 2020. There is also no evidence of nurses reviewing the damaged area of her back for the last three days of this admission. Neither is there evidence of a pressure area care plan despite the fact Mrs D had pressure area damage on her return to the hospital.
38. We find nurses did not follow the Pressure Ulcer Guideline. There is evidence nurses regularly repositioned Mrs D and provided appropriate devices to support her. But they did not assess her risk when she was readmitted to hospital on 12 April 2020. There is no evidence there was an individualised care plan in place at any stage and limited evidence to show nurses regularly reviewed her skin. There is also contradictory information in the records about whether Mrs D had a pressure ulcer when she left the Freeman Hospital.
39. It is difficult for us to establish what the impact of these issues would have been on Mrs D’s health. The evidence suggests Mrs D first developed signs of pressure area damage during her initial admission to the Royal Victoria Infirmary, before her transfer to the Freeman Hospital. She then had recurrent problems with pressure ulcers for the remainder of the admissions we have investigated.
40. We cannot speculate about whether the pressure ulcer would have been prevented if nurses had followed the Pressure Ulcer Guideline. It is possible nurses provided the care Mrs D required and omitted to record this accurately. It is also possible they did not provide the care and that Mrs D experienced pain and discomfort that could have been avoided. But, even with no failings in care the pressure ulcer could still have developed in the same way. At the very least Ms D is left with uncertainty about whether or her mother would have been more comfortable if nurses had followed the relevant standards relating to pressure ulcers.
Nutrition
41. Ms D says her mother was struggling to eat following her surgery on 19 February 2020. She believes her mother was significantly malnourished when she left the hospital on 23 March 2020.
42. The Nutrition Guideline explains how healthcare professionals should identify and care for people who are malnourished or at risk of malnutrition. It says they should screen all patients for malnutrition on admission and then each week or when there is cause for clinical concern. It says they should consider nutritional support for people who have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer.
43. The evidence shows clinicians reviewed Mrs D’s nutritional status shortly after her arrival at the hospital on 18 February 2020. They noted she had no dietary concerns or weight loss at that stage. They concluded she had a ‘Normal’ score which meant they needed to review her nutrition on a weekly basis. No other action was needed at stage.
44. On 25 February 2020 there was a multidisciplinary team review to consider Mrs D’s care. This is because the repeated nutritional status assessment had shown she was then at risk of malnutrition because she was not eating enough food. They asked a doctor to prescribe nutritional supplements. They also started to complete food charts to ensure they were monitoring her intake.
45. One of the doctors was concerned about Mrs D’s ability to swallow and made a referral to the speech and language therapists (SALT) for an assessment. The SALT saw her for the first time on 3 March and again on 13 March. No concerns were identified relating to Mrs D’s ability to swallow. However, two days later nurses were still concerned that she was not eating enough and stressed the importance of monitoring intake. By 18 March this had changed and they considered she was receiving adequate nutrition until doctors discharged her. Records show nurses assisted Mrs D at mealtimes.
46. Mrs D’s GP records showed she weighed 49kg on 17 January 2020. During her first admission to the Royal Victoria Infirmary and the Freeman Hospital her weight remained stable. She weighed 47.3Kg on 10 February and 47.5kg on 21 March. There is no evidence Mrs D lost a significant amount of weight during her time in hospital. Neither is there evidence she was malnourished on 23 March 2020.
47. We find nurses followed the Nutrition Guideline. They screened Mrs D appropriately and provided her with monitoring and support when this was needed.
Mobility
48. Ms D says her mother’s balance and mobility worsened during her admissions to the hospitals. She believes clinicians should have done more to encourage her mother to mobilise.
49. The Medical Adviser told us there are no specific standards relating to responding to changes in a patient’s mobility. However, monitoring a patient’s mobility is an important aspect of general medical care. Doctors must follow Good Medical Practice. This 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 or provide timely treatment and appropriate investigations or referrals if needed.
50. The Medical Adviser told us the clinical records show there was a good standard of holistic medical care for Mrs D. We are persuaded that the records doctors and other clinicians made are accurate. They were completed at the time of the events by a range of different individuals.
51. Physiotherapists and occupational therapists reviewed Mrs D and ordered the equipment she needed to support her at home. Physiotherapy sessions began the day after Mrs D’s surgery. She was able to move independently with a frame and could ‘easily transfer/walk’ with no assistance if needed.
52. A physiotherapist reviewed Mrs D on 2 March 2020. They noted Mrs D could mobilise with a frame but was anxious about it. At that time she needed assistance when transferring from a bed or chair. They planned to work with her to increase her confidence and mobility. There were regular physiotherapy sessions over the following days. These give a picture of Mrs D’s mobility gradually improving.
53. On 16 March 2020 a doctor assessed Mrs D and noted she was doing well with physiotherapy but was ‘not yet safe independently.’ Mrs D told the doctor she was keen to go home.
54. On 18 March 2020 a doctor produced a medical summary about Mrs D. This included information from physiotherapy that Mrs D was ‘virtually independent but tires quickly.’ The next day a physiotherapist noted Mrs D needed minimal help and planned to practice mobility and bed transfers. There was no suggestion over the following days that Mrs D’s mobility worsened.
55. A physiotherapist reviewed Mrs D after her readmission on 12 April 2020. At that point Mrs D was unresponsive. On 14 April physiotherapists encouraged her to stand and move around with a frame and support from one person.
56. By 16 April Mrs D was able to stand independently and move around the cubicle. A physiotherapist reviewed her again the next day and considered it was safe for doctors to discharge her.
57. We have seen no evidence to suggest Mrs D’s mobility worsened while she was in hospital. Doctors were aware that physiotherapists were providing effective treatment to improve her mobility. The doctors gave a good standard of care in this respect and followed Good Medical Practice. We find there were no failings relating to Mrs D’s mobility.
Diagnosis of MND
58. Ms D strongly believes her mother had signs of MND during her hospital admissions between February and April 2020. These included unclear, quiet, speech and laboured breathing. She also says her mother experienced weight loss and mobility problems. She says doctors did not properly investigate her mother’s neurological symptoms.
59. Doctors should have followed Good Medical Practice as explained above. They should also have followed the Neurological Guideline. The Neurological Guideline says when people present with slurred or disrupted speech doctors should refer them for an assessment of neuromuscular disorders. They should do this urgently of there is any evidence of swallowing impairment and immediately if there is any breathlessness when the patient is at rest or lying flat.
60. The Neurological Guideline also says doctors should consider referring adults with isolated and unexplained persistent dysphonia (a quiet, hoarse or wobbly voice) to have an assessment for laryngeal dystonia (involuntary contractions of the vocal cords).
61. On 17 February 2020 Mrs D attended the Royal Victoria Infirmary following a fall in her bathroom. She had a head injury and a fractured left hip. Surgeons operated on the hip but Mrs D took time to recover from the procedure and anaesthetic. She developed type two respiratory failure and needed support from a ventilator.
62. The Medical Adviser told us neurological conditions often present in complex ways. In hindsight Mrs D’s symptoms could have been signs of MND. However, respiratory failure is not unusual in older people who have an emergency operation. Doctors cannot be criticised for not considering MND in this situation.
63. Mrs D spent some time in the intensive care unit. After doctors transferred her to a ward she had signs of delirium but was able to breathe unaided. Doctors noted she had been experiencing a hoarse voice for around four months. They arranged a CT scan which suggested a weakness in her vocal cords. The Medical Adviser told us this was an unusual finding. They arranged a further scan of the nasopharynx (nose and voice box) which was reassuring.
64. Mrs D then had episodes of type two respiratory failure. Doctors were unsure what was causing this. They questioned whether there was a neuromuscular cause (such as MND) noting ‘clinically no clear evidence of neuromuscular disorder or MND. There still could be a possibility that this is early signs of MND.’ They arranged further investigations including lung function tests and sleep studies. They also planned a neurology referral as an outpatient, but it seems Mrs D returned to hospital before this could take place.
65. The clinical records show doctors followed the Neurology Guideline during Mrs D’s initial stay at the Royal Victoria Infirmary and the Freeman Hospital. They made a referral based on Mrs D’s speech and they also considered she met the criteria for a neurological assessment of dysphonia. They also followed Good Medical Practice. They carried out adequate assessments, arranged necessary investigations and treatment and made appropriate referrals to colleagues.
66. Mrs D returned to the Royal Victoria Infirmary on 12 April 2020. At that point she was again experiencing type two respiratory failure. Doctors tried to establish whether this was a neurological or neuromuscular problem and made a referral to investigate this possibility. An ultrasound scan showed possible diaphragmatic palsy (weakness of the diaphragm).
67. The respiratory team initially requested a neurology outpatients appointment. But the neurologists considered MND was ‘unlikely’ as she had no features of that condition. They did not arrange an outpatients appointment. Doctors suspected Mrs D had respiratory failure due to an underlying lung problem. Again, the evidence suggests doctors followed the Neurology Guideline and Good Medical Practice.
68. The Medical Adviser said diagnosing MND can be a complex and lengthy process due to the absence of a single definitive diagnostic test. There are many other conditions with similar symptoms that doctors also need to exclude. There is usually a significant period of time between the onset of symptoms and doctors making a diagnosis. One study identified the average time to be 15 months from symptoms to diagnosis.
69. MND patients often show a range of subtle symptoms in the early stages. These are usually non-specific, such as muscle weakness, cramps and twitching. These can mimic other conditions and make it challenging for clinicians to suspect MND. The progressive nature of the condition is also challenging. But as symptoms progress more definitive signs appear, such as muscle wastage and dysfunction. MND is a rare condition and a GP may see one or two cases in their working lifetime. Hospital doctors may see more MND patients, but it is still a rare and challenging diagnosis to make.
70. The process typically involves evaluation by a neurologist. They may then carry out electromyography (EMG - to assess the electrical activity of the muscles), nerve conduction studies and other imaging tests to exclude other conditions. The extent of these investigations depends on how suspicious clinicians are about the diagnosis, as the tests have risks attached and can be uncomfortable.
71. The Medical Adviser told us there is abundant evidence that doctors gave excellent medical care to Mrs D. They said it was impressive that diagnosis of a neuromuscular disorder was considered at an earlier stage. They said the lack of a diagnosis at this point was not a failure in medical care but the nature of the condition and how it presents and develops over time.
72. We have seen no evidence to suggest doctors failed to inform Ms D that her mother had MND during the admissions we have investigated. This is because they did not make that diagnosis during that period. We can appreciate how distressing it is for her to know her mother probably had MND and this was only recognised a very short time before her mother died.
73. We find doctors from the Trust followed the relevant standards when they cared for and treated Mrs D between 17 February and 17 April 2020. We recognise Ms D is likely to dispute our view about this. We have explained earlier in this report how we can see no evidence of Mrs D losing a significant amount of weight or that her mobility was worsening. While Mrs D’s health problems were likely due to MND we cannot be critical of the doctors for not confirming this diagnosis at an earlier stage for the reasons outlined above.
Resuscitation
74. Ms D says doctors did not speak to her about decisions about whether her mother should be resuscitated. She says there is no evidence they had consent from her mother either.
75. The Resuscitation Guideline explains how clinicians should make decisions about whether to resuscitate a patient in the event of them experiencing a cardiac arrest or stopping breathing. It says if the healthcare team is as certain as they can be that a person is dying as an inevitable result of underlying disease or a catastrophic health event and CPR (cardiopulmonary resuscitation) would not restart the heart and breathing for a sustained period, CPR should not be attempted.
76. The Resuscitation Guideline says it is not necessary to obtain consent from the patient, or those close to the patient, to make a decision not to attempt CPR that has no realistic prospect of success. However, clinicians should explain their decision to the patient or those close to a patient who lacks capacity. Clinicians should make clear and full records of such decisions and the discussions that informed them. Where discussions are not possible they should document the reasons for this.
77. The Resuscitation Guideline says failure to make timely and appropriate decisions about CPR will leave people at risk of receiving inappropriate or unwanted attempts at CPR as they die. It says ‘the resulting indignity, with no prospect of benefit, is unacceptable, especially when many would not have wanted CPR had their needs and wishes been explored.’
78. On 12 April 2020 a doctor recorded that CPR would not be appropriate for Mrs D because of her frailty. At that point Mrs D had acute type two respiratory failure and was receiving non-invasive ventilation. The Medical Adviser told us it is mandatory for clinicians to consider CPR when patients are offered this treatment.
79. The Medical Adviser said that if a patient with Mrs D’s degree of frailty were to suffer a cardiac or respiratory arrest it is virtually certain that resuscitation efforts would not be able to restart the heart. In the very unlikely event that the heart did restart, a patient would normally need a life support machine in intensive care, otherwise the heart would stop again.
80. On 12 April 2020 Mrs D would not have been able to discuss her wishes about resuscitation. Her consciousness was impaired because of the respiratory failure. Even if she had been able to express a view that she wanted to be resuscitated, doctors are not compelled to attempt CPR if they feel it is inappropriate. The Medical Adviser told us it was clear that the decision not to resuscitate in the event of an arrest was the right one.
81. The clinical notes contain only a brief entry in which the doctor noted they had called Ms D to notify her of the resuscitation decision. It should be noted this was taking place in the emergency department during the start of the COVID-19 pandemic so there would have been significant pressures on the doctor. The Medical Adviser said the notes may have been more detailed, and the phone conversation with Ms D longer, if this had been a nonpandemic and non-emergency situation. However, they said the doctor followed the Resuscitation Guideline.
82. We find the doctor who made the resuscitation decision on 12 April 2020 followed the relevant standards.