15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Mr A has claimed.
16. In its complaint responses, the Trust has accepted some failings in nursing care. These relate specifically to some of the points Mr A makes. The Trust accepts that Mrs B’s hand fan was found on the floor under her bed on one occasion and that there were occasions when her hands and nails had not been cleaned properly and her oral hygiene had not been attended to.
17. The Trust has provided apologies to Mr A for the upset caused to him and his brother at the time of the care, and any extra discomfort any errors caused to his mother.
18. Mr A and says these failings, and others, had a significant impact on his mother. He says they contributed to her ‘giving up’ and hastening her death. A specific impact concern of his is that his mother refused care due to her mood being affected by a sudden withdrawal from antidepressant and thyroid hormone medications. He this medication ended up on her gown instead of being swallowed when it was provided in liquid form via a syringe as the cause of this.
19. The Trust responses on the concerns about medication indicate its understanding was that Mr A was concerned about an impact of his mother not getting antibiotic doses. The Trust explains that this medication was given by IV not orally by syringe. It says the medication provided by syringe was to ease stomach upsets. We note that apart from the nursing issues described above, the Trust does not accept any other failings occurred in her care.
20. We have considered both points of view. In order to decide if there are signs of any serious impact or injustice, we obtained specialist clinical advice to provide an overview.
Mrs B’s clinical journey 21. Our adviser was able to explain the facts of Mrs B’s journey as follows:
22. Mrs B had a background of multiple serious health conditions. These included: • COPD (chronic obstructive pulmonary disease) • osteoarthritis • pulmonary embolism (a clot blocking an artery in the lung) • ischemic heart disease (heart failure) • angina (chest pains) • hypertension (high blood pressure) • hypothyroidism (underactive thyroid gland) • depression (for which she was on medication) • rheumatoid arthritis • a pharyngeal pouch (a throat condition making it difficult to swallow).
23. Mrs A was dependent on long term oxygen therapy prior to her admission. On 12 May 2023 she was diagnosed with a chest infection and started on antibiotics by her GP. This did not improve her condition.
24. Her symptoms worsened and Mrs B was admitted to hospital on 17 May, after being brought in by ambulance with worsening shortness of breath. This was thought to be due to an worsening of COPD due to infection and heart failure (fluid on the lungs and or legs due to a weak heart). The medical team were concerned she had developed sepsis, and found she had signs of weakness in the right side of her heart, lung congestion, and initial signs of low kidney function.
25. In addition to her oxygen therapy, Mrs B was treated with nebulisers, intravenous antibiotics, and steroids. From the outset she was periodically, confused non-compliant with her care, removing her oxygen mask, and on occasion refusing personal care and/or medication.
26. Our adviser says Mrs B did not improve significantly with treatment. A chest x-ray on 24 May showed a slight improvement from when she was admitted. On 29 May crackles were heard on her chest and fluid found on her lungs caused by her heart failure. She was given medication to help reduce the fluid. Our adviser identified that there is a recognition in the doctor’s notes at that point, and in subsequent entries, that the Trust were running out of options.
27. In simple terms, Mrs B’s doctors recognised her infection was not clearing and she was still deteriorating despite treatment. This meant that if the infection did not clear she would not survive much longer, and that her family should be kept informed of this.
28. The notes show her poor prognosis was discussed with her son on 30 May. This documents that if she did not tolerate high-flow oxygen (‘Optiflow’) or other forms of oxygen by mask or tubes then the expectation was that she would not survive, and the focus of her care should move to keeping her as comfortable as possible. Sadly, this continued to be the case and all treatment efforts were not able to stop her deteriorating further.
29. Blood tests on 30 May showed that Mrs B was still not responding to antibiotics, her infection persisted, and her kidneys were now failing due to how ill she was. A final change of antibiotics was tried. At this point the notes document that Mrs B’s son was in agreement that, if she failed to respond to this antibiotic too, she would be kept comfortable. This means that all medications would be stopped except those that helped with symptoms.
30. Mrs B continued to deteriorate and died on the morning of 1 June. Her cause of death was recorded on her death certificate as infective exacerbation of COPD. In lay terms this means that she died due to not being able to clear the original infection she was diagnosed with in early May.
31. What the advice provided allows us to conclude, is Mrs B did not get better despite maximum efforts to help her recover from the infection. Her doctors recognised that the infection continued to progress, and if antibiotics were not effective, they would sadly have no way to prevent her death.
32. The evidence shows that despite being on antibiotics for several weeks, including the week her GP had her on antibiotics, her infection did not clear. Mrs B appears to have received all prescribed doses of these, and Mr A does not claim otherwise. He does say that failings in her care hastened her death. We therefore considered if any failings could have altered the outcome for his mother.
Fan use 33. Mr A says staff did not ensure his mother had a fan in use to help with her chronic obstructive pulmonary disease (COPD). It is established that Mr A brought hand fans in for his mother to use and there was an incident where he visited and found one on the floor. This understandably upset him.
34. We see the Trust has apologised for this oversight and reassured Mr A that staff recognise the benefits of fan use for patients with COPD. Unfortunately, it was unable to identify how this failing happened, but we see it took responsibility for a failure to keep these items safe and the impact discovering this had on Mr A.
35. We see Mrs B was receiving oxygen therapy to assist her breathing and her nursing notes include instructions for placing her fan at her bedside and encouraging its use. This is consistent with the Trust’s response. We understand how Mr A may have had a concern about his mother not having access to a hand fan after finding his mother’s fan on the floor.
36. There is little we can find, other than Mr A’s account, to indicate staff were preventing Mrs B using her fan when her son was not present, that this was more than an isolated incident, or had an impact on Mrs B’s overall breathing.
37. Considering the events detailed above, there are much more significant factors that would influence Mr B’s breathing, specifically the fluid on her lungs from heart failure and infection, and her removing her oxygen mask when confused.
38. The impact of this failing is therefore limited, in our view, to the upset caused to Mr A. We consider if the Trust has done enough to put this right later in this statement.
Staff failed to ensure his mother was sat up, against medical advice, and regularly left her lying down 39. Mr A complained to the Trust about his mother being left lying down for the first couple of days of her admission. The Trust responded by saying that Mrs B was encouraged to sit up in bed and in a side chair but at times declined to be repositioned.
40. Our review of the medical records identified many clinical notes over the course of Mrs B’s admission which are consistent with this account. During the first few days after her admission, Mrs B was known to be very confused and unable to orientate to time and place.
41. The medical records do record medical advice upon admission to encourage Mrs B to sit up whenever possible. There is ample evidence in the notes to show her confusion resulted in some resistance to the care being provided, including removing her oxygen mask, declining to be repositioned or receive personal care, and refusing medication on occasion.
42. NMC The Code guidance, section 4.1 states nurse must, ‘balance the need to act in the best interests of people at all times with the requirement to respect a person’s right to accept or refuse treatment’.
43. Potentially Mr A would have more success getting his mother to comply when he was present, as he was her son and a familiar person to her. While these behaviours would not have helped her get better, we also can appreciate that nursing staff would be in a difficult position. They could not force personal care or make Mrs A sit up against her will if she did not wish to co-operate, regardless of whether she was confused at the time or not.
44. Based on the evidence in the records, we have not seen indications that staff failed to ensure Mrs B was sat up, or regularly left her lying down. The evidence indicates she was encouraged to be upright as much as possible, but on occasion did not want to or was unable to. The indications are that nursing staff correctly followed The Code in these instances by respecting Mrs B’s rights.
45. This does not indicate a failure to follow advice but a barrier to delivering it due having to respect the patient’s right to refuse. We are not seeing indications of any wrongdoing in relation to applying this medical advice.
Staff did not ensure his mother’s hands were washed, leaving her with dirty hands and nails and fixadent all over her fingers 46. Mr A complained that he had to clean his mother’s hands every day as they were dirty and had Fixotent (dental adhesive) under her nails. The Trust apologised for staff failing to ensure Mrs A’s hands and nails were sufficiently cleaned. The response advises that new nail kits have been purchased for staff to use and staff have been briefed on the importance of providing patients with personal care.
47. It is difficult to establish the facts on this point as there is little in the medical records to go off. As both parties agree there was a failing in nursing care here, we do not question this and so we have considered the impact.
48. We are unable to see how this could have an impact on Mrs B’s overall clinical state as that was driven by respiratory and heart failure among other chronic conditions. It clearly caused Mr A upset, and we take his point about how this may have contributed to Mrs B’s low mood. We consider if the Trust has done enough to put this right later in this statement.
Staff failed to clean his mother’s dentures and left them in for four days 49. Mr A complained that his mother told him she had been left with her dentures in with no assistance for four days, and when he helped clean them, he found bits of food and medication. As with the concerns about hand care, the Trust has apologised and outlined new measures put in place to improve personal care following this incident.
50. Again, it is difficult to establish the facts on this point as there is little in the medical records to go off. As both parties agree there was a failing in nursing care here, so we have considered the impact.
51. This also led to upset for Mr A, and we think it likely from his account that Mrs B also suffered extra discomfort and this potentially contributed to her low mood. While we can see this may have be unpleasant for Mrs B there seems little wider impact on her overall clinical state for the reasons explained above. We consider if the Trust has done enough to put this right later in this statement.
Staff attempted to take blood samples at the same time as giving oral syringe medicines 52. Mr A complained about an incident he witnessed where one staff member was attempting to obtain a blood sample from his mother’s arm at the same time as another was giving her medication via a syringe into her mouth. He says this distressed him and his mother and she was unable to swallow her medication and dribbled it onto her gown. He says from marks on her gown at other time this appears to have been not an isolated occurrence.
53. In his complaint to us Mr A says his mother’s thyroid and antidepressant medication would have been in the syringe along with other regular medicines. He says that withdrawal side effects from these medicines led to his mother giving up.
54. We note the Trust has apologised for this incident, so we do not question it occurred. It has apologised and fed back to the phlebotomy team (whom we assume the staff member taking bloods would have been under) to ensure staff know to avoid mismanaging multiple tasks in this way.
55. It is clear this event also upset Mr A. We can understand why he would be concerned about his mother not getting her regular dosages of medicines if she was not swallowing them. We also note the Trust’s point that Mrs B refused medication on occasion so it is clear that, for one reason or another, she would have missed some doses during her admission.
56. To consider if the impact could be more than the upset already acknowledged, we asked our adviser if it would be possible that Mrs B could have been affected in the way Mr A says. They provided information from a clinical study on thyroid medication withdrawal explaining that adverse reactions to stopping this medication would take weeks to develop, so there is little possibility of this being linked to Mrs B deterioration in mood.
57. Our adviser also cited guidance from the BNF on Citalopram use which lists the known side effects from sudden withdrawal. This explained that gastro-intestinal disturbances, headache, anxiety, dizziness, paraesthesia, electric shock sensation in the head, neck, and spine, tinnitus, sleep disturbances, fatigue, influenza-like symptoms, and sweating are the most common features.
58. Our adviser said it is very difficult to says Mrs B definitely did not have some of these symptoms due to citalopram being suddenly discontinued, as she was severely ill upon admission. However, they said her deterioration and death are much more in keeping with infection and respiratory illness, which does not fit with citalopram withdrawal, or thyroid medication withdrawal.
59. On balance of probability, we do not think there is enough to indicate the impact claimed. Mrs B was confused upon admission, intermittently non-compliant with care, and her medical notes establish her mood was low from the outset and did not significantly improve or get worse during her admission. This is understandable as she was seriously ill.
60. It would not have been possible for her to have been entering withdrawal at the start of her stay in hospital if she had been receiving her full medications at home to that point. Yet the depression and despondency Mrs B exhibited appear to have been present from the outset.
61. It seems likely that being severely unwell was a larger factor driving Mrs B’s low mood, so while we agree that there was a failing here, we hope this reassures Mr A that there is little sign of the impact he feared. Again, we consider if the Trust has done enough to put this right later in this statement.
Consideration of remedy and summary 62. Based on the above we have seen that there are indications of some minor failings in nursing care which have led to upset for Mr A, and in some cases avoidable discomfort for Mrs B. This, we believe is the injustice that required putting right. There is little to support the view of there being more serious issues with the care provided, or the failings contributing in any significant way to her death.
63. We understand how he may feel his mother may have ‘given up’ trying to get better due to these shortfalls in care. The overview of care provided by our adviser suggests it would sadly not have been possible to prevent her death, whether these failings happened or not.
64. According to our adviser, this seems to have been fundamentally driven by Mrs B reaching the end of her natural life. Her multiple chronic health problems reached a tipping point after many years of managing these with the support of her sons. Unfortunately, she was now physically too frail for her body to fight infection, and her circulation was faltering, both of which made her COPD worse.
65. We do not underestimate how difficult these events were for Mr A or wish to diminish his mother’s suffering at the end of her life. This would be unavoidable with the loss of a loved one. The personal care failings in this case will have not helped at a very emotionally distressing time but are not the cause of that distress. Nonetheless, this additional burden should be recognised by the Trust.
66. Our Principles for Remedy – Putting things Right says, ‘In many cases, a prompt explanation and an apology will be a sufficient and appropriate response.’
67. As the impact of this incident does not appear to have affected Mrs B clinically and the impact is the upset caused to Mr A, we think the apologies and reassurances provided are enough to place Mr A back in the position he should be, addressing the worry and upset caused at the time.
68. As the Trust has acted proportionately and responsibly in addressing the impact of what went wrong, we do not consider there is any more that should be done to remedy this complaint. For this reason, we do not think we should investigate further. We accept that Mr A may find this view disappointing, and we are sorry if this causes him further upset.