24. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Discharge
25. Mrs A is concerned the Trust discharged her husband in June 2023 when his blood sugar levels were not stable. Mrs A told us she thinks her husband should have remained an inpatient until the Trust stabilised his levels. She told us Mr A’s levels were out of control when the Trust sent him home.
26. Mrs A told us she did not have an idea how to manage this and asked the Trust what she should do for Mr A. She said the Trust told her to concentrate on keeping Mr A’s blood sugar levels up. Mrs A explained she monitored Mr A’s blood sugar levels at 20-minute periods but remained concerned he was going to fall into a diabetic coma. Mrs A believes the Trust caused Mr A’s health to decline by not managing his diabetes properly and sending him home, instead of keeping him in hospital where he may have got better.
27. When admitted to hospital on 1 June 2023, Mr A was taking gliclazide to control his Type 2 diabetes. Mr A’s records show the Trust monitored his blood sugar levels daily, and he was seen by the diabetes nurse during this first admission on 6 June 2023. The Trust referred Mr A to the nurse after he had hypoglycaemia (a condition when blood sugar levels drop too low).
28. Mr A’s medication was changed, and he was directed to stop taking gliclazide with the aim of improving his levels and keeping them above 4 mmol/L. The diabetes nurse instructed Mr A to continue with his other diabetic medication (metformin) and signposted him to his GP if his levels went above 12 mmol/L. The nurse shared her advice with the ward staff tending to Mr A. The nurse concluded no further diabetes inpatient input was required.
29. Mr A’s records show he was discharged from the Trust the next day, on 7 June 2023. The Trust documented Mr A had some low blood sugar readings whilst an inpatient that required him to take glucogel (a gel used to quickly raise blood sugar). It referred Mr A to his GP surgery for a further review and asked it to repeat blood tests required for those with diabetes (also known as HbA1c tests). It also recommended ongoing monitoring of Mr A’s bloods.
30. On discharge, the Trust advised Mr A to wait for follow up appointments and to continue to monitor his blood sugar levels before meals and bedtime. It requested he also contact his GP for further support and monitoring relating to his diabetes. Mr A’s records show this advice was discussed with him and he confirmed he would contact his GP for a review.
31. GMC GMP guidance says clinicians must provide a good standard of practice and care. If assessing, diagnosing or treating patients, clinicians must refer a patient to another practitioner when this serves the patient’s needs.
32. Our adviser explained it was appropriate for the Trust’s surgical team to refer Mr A to its diabetes nurse when it identified concerns with his low blood sugar levels. Our adviser said a patient is at risk of a falling into a diabetic coma when blood sugar readings fall below 4mmol/L. They told us the Trust’s actions were in keeping with GMC guidance. We share this view.
33. Mr A’s records reflect his blood sugar levels were unremarkable on the first two days of his admission. On 3 June 2023, Mr A had a reading of 3.8 mmol/L in the evening and glucogel was given to raise his blood sugar. A reading taken nearly 30 minutes later showed this had risen to 4.9 mmol/L. On 5 and 6 June 2023, Mr A’s blood sugar had dropped to levels indicating hypoglycaemia. It was then the Trust referred Mr A to its diabetes nurse.
34. Mr A’s records show the Trust monitored his blood sugar periodically throughout the day during his inpatient stay. Mr A’s final reading on 7 June 2023, the day of his discharge, was 5.7 mmol/L. We can see this was above the reading which would indicate Mr A was at risk of a diabetic coma.
35. Our adviser reviewed Mr A’s blood sugar readings during this time and told us his results were not dramatically changing and were not remarkably low to require extending his inpatient stay. They explained it was reasonable for the diabetes nurse to stop medication (gliclazide) which is used to help lower blood sugar levels to help improve Mr A’s readings and help them to stay above 4 mmol/L, which we can see it did in Mr A’s case as his final reading shows.
36. We can understand why Mrs A would question the appropriateness of Mr A’s discharge now it is known he became severely unwell soon after. We have carefully reviewed Mr A’s medical records and have not identified an indication the Trust should have kept Mr A in hospital to stabilise his diabetes.
37. We consider the Trust acted in line with GMC GMP guidance mentioned above. This is because the evidence shows the Trust discharged Mr A when his blood sugar levels were above 4mmol/L and not indicating he was at risk of having a diabetic coma. This means we see no indication of a failing here.
DNACPR
38. Mrs A told us she received a call on 14 June 2023 from the Trust about a DNACPR for her husband. Mrs A explained that this was the first time this was discussed with her, despite her visiting Mr A in hospital earlier that day.
39. Mrs A told us prior to the call she had hope Mr A would undergo further treatment which might have prolonged his life. On the call Mrs A says she was informed Mr A was given the worst possible outlook. Mrs A explained she was not aware of how unwell her husband was. We are sorry to learn of the distress this caused and recognise this must have been extremely upsetting to hear.
40. In its response to Mrs A, the Trust acknowledged it called her to discuss its decision to place a DNACPR on Mr A’s records. It explained it did this due to Mr A’s sudden deterioration, and said it did not anticipate Mr A was at immediate risk of dying. It apologised for the impact it caused and provided feedback and learning to its medical and nursing staff.
41. We have reviewed Mr A’s records and can see the Trust put a DNACPR in place on the evening of 14 June 2023. The doctor who considered this documented resuscitating Mr A would be no clinical benefit to him. This is because he had an advanced form of stomach cancer, kidney failure and pneumonia (a lung infection). Mr A sadly died the following day.
42. The records show on 14 June 2023 at 3.26pm the Trust discussed Mr A’s diagnosis with him, his wife, Mrs A, and his sister present. The record says an internal scan (CT scan) was discussed with them which confirmed Mr A’s cancer had spread. The nurse discussed treatment options with Mr A and explained he was too unwell to receive treatment at that time, but should his condition improve, this would be palliative care which would not cure Mr A’s cancer. The record says Mr and Mrs A understood what this meant.
43. Mr A’s records show later that day, the Trust telephoned Mrs A in the evening to discuss Mr A’s prognosis and the DNACPR it had put in place. It explained because of Mr A’s cancer and organ failure if his condition were to worsen, it would not be appropriate for it to provide artificial organ support.
44. It also said it would not be appropriate to resuscitate Mr A, as sadly he would not survive to leave hospital. We recognise this must have been a very distressing time for Mr and Mrs A.
45. GMC end of life guidance says discussions about DNACPRs must be based on the circumstances of the patient, taking into account their wishes and preferences. The guidance also says with the patient’s consent, those close to the patient may want or need information about the patient’s diagnosis and about the likely progression of their condition to help them provide care and recognise the patient’s condition. It says clinicians must approach such discussions sensitively.
46. We appreciate Mrs A feels she was not made aware about how unwell Mr A was before the DNACPR was communicated to her. We recognise this must have been a very difficult conversation to have, especially on the telephone. We understand any discussions about end-of-life care are especially hard to have. We have carefully considered if there is any indication of a failing in the Trust’s communication of its DNACPR decision without Mrs A previously being aware how unwell he was.
47. BMA, the Resuscitation Council and Royal College of Nursing guidance says effective timely communication is essential to ensure decisions about CPR are made well and understood clearly by all those involved, including those close to the patient.
48. We can see from Mr A’s records earlier in the day on 14 June, the Trust had discussed Mr A’s cancer prognosis and treatment options with him and his family. The DNACPR was later discussed with Mr A at 8.58pm after clinicians said his condition was not improving. Notes show that by 9.51pm the Trust had been in touch with Mrs A on the phone to discuss this with her after some unsuccessful attempts. It explained Mr A had become more unwell overnight and sadly, that he was unlikely to get better.
49. Our adviser explained when a person is nearing the end of their life there are medical signs and symptoms clinicians look for. These include a patient’s presentation, how they are functioning, along with medical assessments which include monitoring and repeating observations. They told us a NEWS2 (National Early Warning Score) tool is used in these situations to assess how poorly a person is. NEWS2 is used to provide patients with a score and high score reflects how unwell a patient is.
50. Mr A’s records show on 13 June in the late evening his NEWS2 score was noted as 4. On 14 June in the early evening, Mr A’s NEWS2 score increased to 8. We can see at approximately 8.20pm a nurse noted his increased NEWS2 score, and that Mr A required more oxygen. As a result, the nurse requested for a doctor to come and review Mr A. As we have described in paragraph 46, we can see the doctor reviewed Mr A’s condition at around 9pm.
51. Our adviser reflected on Mr A’s records at this time and told us he had elevated respiratory and lactate levels, along with a high NEWS2 score of 8. Our adviser explained these results indicate how unwell Mr A was and when considered together with Mr A’s presentation, supports the Trust’s view that Mr A’s condition worsened quickly that evening.
52. Taking the records and the advice we have received into account, we consider the Trust did not have an opportunity to make Mrs A aware of how poorly Mr A was before it discussed his DNACPR with her. This is because as we now know, Mr A was deteriorating suddenly and quickly from the time Mrs A left the hospital. Based on the evidence we have seen we have not identified departures from the guidance referred to above. We recognise Mrs A was deeply upset by this matter and hope our decision assures her that we have not identified an opportunity where it should have told Mrs A any sooner of its decision to put a DNACPR in place.
Communication around diagnosis
53. Mrs A says the Trust incorrectly informed them Mr A had a blood clot on his lungs after he had a chest x-ray. Mrs A was later told this was pneumonia. Mrs A explained the Trust only corrected this diagnosis on the day Mr A died.
54. In its response to Mrs A the Trust said it had reviewed Mr A’s medical records and understood there were concerns about a blood clot due to findings on a recent x-ray but that at the time, Mr A was too unwell for further investigations. It later identified this as pneumonia and not a blood clot. The Trust apologised for it not making Mr A’s diagnosis clear. It said it would feedback to the medical team about clearer levels of communication.
55. GMC Guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them the information and support they need.
56. We have no reason to doubt Mrs A’s account that from the communication she and her husband had with the Trust, that they understood his diagnosis to be a blood clot. The evidence available to us is Mrs A’s recollection and the documentation in the medical records. We found an entry in the records made by a consultant at the Trust who spoke with Mrs A on 14 June 2023.
57. The entry in Mr A’s records made by the consultant says ‘Explained how unwell [Mr A] is. Unfortunately, he has become more unwell overnight. Trying to treat kidneys and pneumonia[…].’ We note this was sadly the day before Mr A died.
58. Mr A’s records show he had a chest x-ray the day before. The Trust reviewed the imaging and noted an abnormality which indicated infection or fluid build-up. It also reported on the scan that a blood clot could not be excluded. On this basis, we do not think it was unreasonable for the Trust to refer to a blood clot in discussion with Mrs A. We can see based on the x-ray findings, it decided to treat Mr A for hospital acquired pneumonia in line with guidance.
59. Our adviser explained that it can sometimes be difficult on x-rays to tell if a patient has a blood clot or pneumonia, as was the case for Mr A. They told us, in such cases, it is normal to form a differential diagnosis. This is a method used by clinicians to identify a diagnosis and includes listing possible conditions causing a patient’s symptoms. During this process, clinicians will gather information using testing to help narrow down the condition.
60. We recognise there is a difference in account between what Mrs A told us about the Trust’s communication around her husband’s diagnosis and the entry it made in his record. Sadly, we can never be definitive about what happened.
61. Based on the overall quality of the medical records we think it reasonable to conclude on balance of probabilities it is likely the Trust referred to pneumonia as well as a blood clot. The limits of the available evidence mean we cannot draw robust conclusions on the quality of the verbal communication. This means we have not found indications that the Trust gave incorrect information about the diagnosis or departed from GMC guidance on communication here. We thank Mrs A for describing such difficult events to us.
62. We thought it may be helpful for Mrs A to know what our adviser told us, that the miscommunication Mrs A told us about would have made no significant difference to Mr A as he received appropriate treatment for his pneumonia. We accept this advice and hope this provides some reassurance to Ms A.
63. We are very sorry to hear of how distressing this time was for Mrs A to see her husband become so unwell, and we understand why she believes different treatment could have changed the outcome for him.
64. Through our work, we have not seen the Trust has departed from guidance as Mrs A says. We have not found any indications of failings and consider the Trust acted reasonably in looking after Mr A during this time.
65. As we have not seen any indications of failings which led to any poor outcome for Mr A or injustice to Mrs A, we will not investigate further. We hope this information brings some resolution for Mrs A’s concerns.