Admission 9. Miss Y complains about the amount of time the Trust took to admit her mother to the ED from an ambulance on 14 January. She is concerned that her mother waited for over seven hours in the ambulance before being admitted. We were sorry to hear that her mother had to wait in an ambulance for such a long time. We recognise that this must have been distressing for her mother who was very unwell.
10. Our adviser confirmed that there are no national guidelines to say how quickly a patient should be admitted to hospital from an ambulance. They explained that whilst patients are in an ambulance, they remain under the care of the paramedics. Paramedics can undertake physiological observations and give treatment such as oxygen, fluids, pain relief, and antibiotics. They went on to say that an extended handover time between an ambulance and the ED can result in a delay in tests and may be uncomfortable for the patient.
11. The medical records show that Miss Y’s mother’s NEWS was zero when the Trust admitted her on 15 January. NEWS is a scoring system which improves the detection and response to clinical deterioration in patients. A score of zero is the lowest score using the tool.
12. Our adviser explained that a NEWS of zero suggests that Miss Y’s mother did not significantly deteriorate whilst she waited in the ambulance, and it does not appear that she was impacted physically by the long wait. However, it is understandable that it would have uncomfortable for her to spend that amount of time in the ambulance.
13. Our Principles of Good Complaint Handling say that organisations should provide honest, evidence–based explanations, acknowledge mistakes and apologise, and use lessons learned from complaints to improve service delivery.
14. In its response, the Trust explained it was experiencing a high volume of attendances when Miss Y’s mother attended the ED. It said the wait her mother experienced was below the standard it hopes to achieve and apologised for this. It said it is working with its system partners to increase capacity and flow within all the departments to improve the patient experience.
15. Although there are no relevant guidelines to follow, we can see the Trust has acknowledged and explained what happened. It has also apologised and explained what it is doing to try and improve its service. This is in line with our Principles as it has explained what happened clearly and openly.
16. Based on the evidence we have seen and the clinical advice, we have seen no indication that something went seriously wrong. We are satisfied that the Trust has explained what happened in line with our Principles of Good Complaint Handling. We hope the information from our adviser reassures Miss Y that her mother’s prolonged wait in the ambulance did not appear to impact her overall condition.
Communication 17. Miss Y complains the Trust did not communicate with her or the family by listening to their concerns or taking account of her mother’s medical history. She explained that her mother had stopped eating prior to her admission, and she had not been taking her medication. She worries that the Trust did not take this information into account.
18. GMC guidance say clinicians must communicate effectively by being considerate to those close to the patient and be sensitive and responsive in giving them information and support. As above, the guidance also says when they assess, diagnose, or treat patients, clinicians must take account of their history.
19. Our adviser has confirmed that the Trust took a detailed medical history for Miss Y’s mother when it assessed her. It noted that she had a history of a stroke, vascular dementia, and other medical problems. We can also see evidence that it took information from Miss Y about her mother’s history including that she had not eaten for some time before her admission.
20. Therefore, we are satisfied that the Trust took account of Miss Y’s mother’s history in line with GMC guidance above as it assessed her and documented her medical history. It also appears to have followed GMC guidance on communicating effectively, as it listened to Miss Y and noted her concerns when she told it her mother had not been eating.
21. Based on the evidence we have seen and the clinical advice, we have seen no indication that anything went wrong, and the Trust followed relevant guidelines when it took account of Miss Y’s mother’s history and communicated with her family.
Pain management and medication 22. Miss Y is understandably concerned the Trust did not consider using a medication to thin her mother’s blood despite her history of a stroke. She also says that her mother was in pain and uncomfortable, but the Trust did not give her adequate pain relief.
23. We were sorry to hear Miss Y’s concerns about how the Trust managed her mother’s pain relief and blood thinner medication. From what she told us, it has clearly been a distressing time for her, and we are sorry that her concerns about the Trust’s management of her mother’s medication continue to impact her.
24. GMC guidelines say when clinicians provide clinical care, they should prescribe drugs when they are satisfied that they serve the patients’ needs and take all possible steps to alleviate pain and distress. The guidelines say if they assess, diagnose, or treat patients, they should adequately assess the patient’s conditions, taking account of their history.
25. The medical records show that when the Trust admitted Miss Y’s mother in the early hours of the morning on 15 January, it assessed her, noted her medical history, and documented that she was in pain. We can see that it prescribed intravenous (IV) paracetamol and oral morphine and administered these medications. There are further entries in the medical records to suggest the Trust continued to assess her mother’s pain and documented her pain levels.
26. Our adviser explained that the Trust assessed and treated Miss Y’s mother and gave her pain relief when she needed it. Therefore, it appears the Trust’s actions when it managed her pain appear to be in line with the GMC guidance above as it assessed her, prescribed drugs to suit her needs, and took all possible steps to alleviate her pain.
27. The medical records also show that Miss Y’s mother was not on blood thinner medication when the Trust admitted her. It appears her GP had made the decision to stop this medication before she was admitted. Therefore, it was not the Trust’s decision to stop this medication.
28. Our adviser explained that Miss Y’s mother’s international normalised ration (INR) blood test result indicated that her blood was already thinner than normal, so she did not in fact need any additional blood thinning medication. The INR is a marker of how thin the blood is.
29. We hope this information from our adviser helps to reassure Miss Y that the Trust did consider using a blood thinner after completing a risk assessment in line with GMC guidance on assessing patients. However, her mother’s INR result meant that she did not need one.
30. We hope our findings give Miss Y some reassurance that the Trust acted within guidelines, and nothing went wrong when it made decisions about her mother’s pain relief and blood thinning medication.
Tests and treatment 31. Miss Y complains that the Trust did not take her mother’s condition seriously. She is concerned that it did not treat her as an emergency patient but instead like a patient with dementia. We were sorry to hear Miss Y’s concerns about how the Trust treated her mother and it is understandable that this concern continues to cause her ongoing distress.
32. GMC guidelines say clinicians must promptly provide or arrange suitable investigations or treatment when necessary.
33. We can see evidence in the medical records that the Trust carried out investigations for Miss Y’s mother during her admission. These investigations included blood tests, an ECG, and X-rays. We can also see that it gave her IV fluids, IV anti-sickness treatment, and IV paracetamol.
34. Our adviser explained that the tests the Trust carried out are standard investigations and it appears it gave her active treatment with the above pain relief and IV treatment. They cannot see any evidence that the Trust withheld tests or treatments due to Miss Y’s mother’s dementia.
35. Therefore, it appears the Trust promptly provided suitable investigations and treatment, when necessary, in line with the GMC guidance above. It appears the Trust took her condition seriously and nothing went wrong. We hope the information from our adviser reassures Miss Y that that the Trust did not withhold any treatment from her mother due to her dementia.
36. Miss Y is understandably concerned that her mother’s abdominal X-ray was not reported on until three days after her sad death. She told us she thinks her mother needed an urgent bowel operation and the Trust missed this because the X-ray was not reported on in a timely manner. She says that her mother’s sad death could have been avoided.
37. We were sorry to hear that Miss Y has concerns that her mother may have had a different outcome if the Trust had reported the X-ray sooner. From what she told us, it is clear Miss Y’s concerns continue to cause her pain and distress.
38. The Trust’s policy on plain film reporting says that routine X-rays should be reported within 14 days of the X-ray examination and urgent X-rays should be reported within two days. It organised an X-ray of Miss Y’s mother’s abdomen on 15 January to rule out a bowel obstruction as she had abdominal pain. It formally reported the X-ray results on 20 January, five days later. A formal report means that a radiologist views the X-ray images and provides a report on the findings and meanings of the image.
39. The Trust has confirmed that Miss Y’s mother’s X-rays were routine so the reporting deadline for the images was 14 days. Therefore, the Trust followed its own policy as it reported the X-ray within five days, well within the 14-day deadline. Therefore, it does not appear that anything went wrong.
40. Our adviser explained that although the X-rays were reported on after Miss Y’s mother’s sad death, the Trust had reviewed the images after they were taken, and its observations noted in the medical records, matched that of the formal report. They explained that her mother did not have clinical signs of significant bowel obstruction as her abdomen was soft to touch and not tender.
41. They explained that sadly, it appears her mother had been slowly deteriorating at home prior to the admission and unfortunately, she had a cardiac arrest. They went on to explain the Trust could not have been prevented or predicted her sad death. We hope the information from our adviser goes some way to reassure Miss Y that the fact her mother’s X-ray was reported on after her sad death, did not impact the eventual outcome.
42. Overall, based on the clinical advice and the evidence we have seen, it appears the Trust followed relevant guidelines when it managed Miss Y’s mother’s care between 14 and 16 January 2022. It is understandable that Miss Y’s concerns have caused her the ongoing pain and distress she described. We hope that our report and explanations go some way to reassure her that her mother’s sad death could not have been prevented.