Diabetes management – medication
14. Management of Hyperglycaemia and Steroid (Glucocorticoid) Therapy says if a patient is on medication that affects their blood sugar then doctors should monitor their blood sugar four times a day. This checks the medication is working and indicates if doctors need to adjust it.
15. If monitoring shows a patient’s blood sugar has fallen too low (hypoglycaemia) then doctors should reduce the medication they are using to lower the patient’s blood sugar. In this instance doctors were giving Mr G a type of medication that helps the body make more insulin. Insulin regulates the amount of sugar in someone’s blood.
16. Mr G’s blood glucose monitoring chart shows staff measured the amount of sugar in his blood at least four times per day every day throughout his admissions. The readings show Mr G’s blood sugar sometimes climbed too high or fell too low. The prescription record demonstrates doctors adjusted Mr G’s medication in response to these readings.
17. We understand how worrying it has been for Mrs G to believe staff did not manage her husband’s diabetes appropriately. We have found staff monitored Mr G’s blood sugar and responded to changes in line with the relevant guidelines.
Diabetes management - nursing
18. The Trust did not have a local policy setting out how soon it should provide specialist diabetes nursing. Likewise, there is no national guidance to say when a specialist diabetes team should visit a patient.
19. A diabetes specialist nurse is responsible for assessing a patient’s overall glucose control and their glucose lowering medicines. They would also suggest any appropriate changes. These nurses are particularly skilled in the management of insulin dosing, which is typically outside the expertise of the medical staff who usually saw Mr G on the ward.
20. Our adviser explained Mr G had recently started insulin when admitted to hospital. At the time his blood sugar was unstable and he had suspected low blood pressure. Therefore, it was appropriate for doctors to ask the specialist diabetes team to review him. Our adviser would expect this review to happen within a few days.
21. Doctors first requested specialist input on 18 January - the day after Mr G’s first hospital admission. However, it took until 9 February for the diabetes nurse to visit Mr G. This was 17 days later.
22. When the specialist nurse first saw Mr G they reviewed his condition and stopped his insulin. Mr G’s confusion did not get better immediately but he was fully alert and communicating with staff by 17 February.
23. The Trust’s complaint response acknowledged specialist staff took too long to visit Mr G. It explained the hospital was under ‘extreme pressure’ at the time because of the number of patients requiring admission.
24. Admissions data from the time shows approximately 800 of the Trust’s 889 beds were occupied when Mr G visited hospital. Just under 200 patients had COVID-19.
25. Although these admissions explain the delay at the time, we expect staff to prioritise patient care. We have found this delay was a failing.
26. Mrs G says because the Trust did not manage her husband’s diabetes properly it meant he was confused and distressed. She says she and her family found it exceptionally upsetting to hear her husband in this condition. She also says the confusion made it difficult to discuss his health with him, which caused uncertainty and added to their worry.
27. Mr G had several problems doctors had to manage. This included an infection, low blood pressure, shortness of breath, disorientation and COVID-19. Managing these competing problems was challenging and explains why it required input from specialist diabetes nursing.
28. Given these factors it is unlikely the involvement of specialist nursing would have stopped Mr G’s confusion. This is because any of his several illnesses could have reasonably caused confusion. Further, there was a significant delay between the diabetes nurse’s involvement and Mr G’s improvement.
29. Nonetheless, we recognise Mrs G would have found it reassuring to know the right specialist staff were managing her husband’s diabetes. We understand her distress in feeling the Trust did not look after her husband in a supportive and comprehensive way.
30. The Trust could have eased this worry if it had acted differently. We have considered what it has done to resolve the impact of the failings.
31. The Trust’s complaint response accepted its nursing care took too long. It sent a sincere written apology to Mrs G for this and the impact she experienced. Further, it raised the problems at its Clinical Governance Meeting so the staff could reflect on their actions and improve their medical practice.
32. These actions go some way to reassuring us the Trust has understood what went wrong. However, the actions do not go far enough to improve services or recognise the individual experience Mrs G has told us about. We have therefore set out some recommendations to put this right at the end of this report.
End-of-life decision
33. NICE guidance ‘Care of dying adults in the last days of life’ says doctors should assess the patient’s active illnesses. They should also consider how the illness will likely develop and base their view on the patient’s vital signs. This includes things like the patient’s consciousness, breathing, blood pressure, temperature and urine output.
34. Doctors should use the knowledge gained from their assessments alongside information gathered from the individual and those important to them. This should be used to determine if the person is nearing death, stable or improving. Changes in the patient’s condition should be monitored at least every 24 hours and their care plan updated.
35. Doctors believed Mr G was approaching the end of his life on 29 January. They based this on the fact he had COVID-19, his breathing was shallow, and his severe confusion meant he could not communicate properly.
36. Mr G’s condition improved in the following two days as he was alert to his surroundings and communicating better. This is reflected in Mrs G’s daughter’s diary which says Mr G was conscious and drinking. Therefore, doctors took Mr G off endoflife care on 31 January and began actively treating his illnesses again.
37. As doctors accounted for Mr G’s symptoms and illnesses when they decided he was approaching the end of his life, we are satisfied they followed relevant guidance. Likewise, when his condition improved they followed guidance by considering the evidence and reversing this decision.
38. We understand how upsetting this sad series of events has been for Mrs G. We recognise just how worrying it was to believe Mr G was in the final hours of his life and the uncertainty she experienced when he started to get better.
DNACPR process
39. ReSPECT is a decision-making process to determine what someone’s future emergency care should be. It is used to plan treatment for when a patient cannot make or communicate their choices.
40. Guidance from the Resuscitation Council on how to use the ReSPECT process says decisions should be discussed with a patient and their family. This should be documented to include why the doctor was making the decision not to resuscitate, where the discussion happened and how the family reacted.
41. In this instance, ReSPECT was used to decide on DNACPR. DNACPR is a decision to not attempt cardiopulmonary resuscitation (CPR) when someone’s breathing and heart stops. CPR is a series of techniques which try to restart the heart and breathing and restore circulation.
42. On 19 January a doctor spoke to Mr G about DNACPR. They explained the risks of resuscitation and why they believed it was unsuitable for his condition. Records show Mr G and the doctor agreed DNACPR should be in place. The limit of care at the end of his life would be a mask to help him breathe.
43. We do not have a copy of the first ReSPECT form but we do have the discharge note from 22 January. This said a DNACPR decision was in place but there is no record of a discussion about it with Mr G’s family.
44. Mrs G says she and her husband first learned of the advance DNACPR decision when he returned home from hospital. She says they looked through his medical records and were surprised to see the ReSPECT form explaining doctors would not attempt to resuscitate Mr G. She has explained to us Mr G wanted to live.
45. The diary Mrs G’s daughter made corroborates what Mrs G has told us. It added Mr G changed his mind about resuscitation when he read through his medical notes at home. He apparently called the doctors at the hospital and asked them to change the DNACPR decision.
46. Mr G went back into hospital on 23 January and doctors agreed with Mrs G to withdraw the DNACPR decision.
47. On 27 January a doctor spoke to her and agreed to discuss resuscitation further when results from a scan of Mr G’s brain came back. Mrs G has told us she asked the doctor not to make any decisions on DNACPR without giving her husband the chance to discuss things with her.
48. Mr G was then treated as though he was approaching the end of his life. After he got better, doctors spoke to him about DNACPR on 1 February.
49. The consultant looking after Mr G signed a ReSPECT form indicating he was not for resuscitation. Notes recorded Mr G had capacity to make decisions for himself at the time and was fully involved in discussions about his care. The form says they discussed this decision on 1 February and Mr G agreed not to try resuscitation.
50. There are no indications doctors gave Mrs G the chance to discuss this decision with her husband or spoke to her directly about DNACPR.
51. It was a failing doctors did not involve Mrs G or her family in DNACPR decisions. That said, we can see when Mr and Mrs G challenged the decision doctors took this into account and had further discussions about whether to try resuscitation.
52. As we have found a failing we have considered the impact this had.
53. Doctors should account for the views of those close to the patient. However, the ultimate decision about whether to resuscitate someone is a medical one. Doctors have no obligation to attempt it if they believe it would be inappropriate, as they did in this instance.
54. We also recognise an advanced decision not to resuscitate someone would likely be upsetting for those close to the patient. However, a doctor’s explanation of the decision would likely have allowed Mrs G to understand why it was made. In doing so, it would lessen how upsetting this was for her.
55. The Trust spoke with the doctor responsible for the DNACPR decision. The doctor accepted there is no note of a conversation with Mrs G and apologised for this. The Trust reiterated this apology and agreed its communication could have been better. It also raised Mrs G’s concerns at a team meeting between staff.
56. Whilst these actions are reassuring they do not go far enough to recognise the individual experience of Mrs G. We have set out a recommendation below to put this right.