Diagnoses of urosepsis and acute kidney injury
24. Miss D says there was a delay in the Trust diagnosing her mother with an acute kidney injury (AKI) and urosepsis until shortly before her death and believes these were present much earlier on. The Trust has attributed Mrs D's raised CRP (C-reactive protein, a non-specific marker in the blood for inflammation or infection) and procalcitonin (a substance produced by the body in response to bacterial infection) levels to COVID-19. Abnormally high procalcitonin can be a sign of sepsis.
25. Our physician adviser noted the Trust only identified urosepsis after Mrs D’s death, on the advice of the medical examiner. This was based on a retrospective review of the clinical records.
26. We considered if the Trust identified Mrs D’s AKI and urosepsis at the earliest opportunity.
27. NICE guideline 148 ‘Acute kidney injury: prevention, detection and management’ says people who are acutely unwell, and meet certain criteria, should have their serum creatinine checked to establish if they have an AKI. Mrs D met that criteria.
28. Our physician adviser confirmed the Trust checked Mrs D’s blood results two days before the Trust discharged her on 27 October. This was in line with the NICE guideline. The results showed her kidney function was normal, which means there is no evidence she had an AKI at that point.
29. Our physician adviser also confirmed there were no clinical signs documented about Mrs D’s presentation to raise suspicion of an AKI. They said there were also no signs to indicate she had a urinary tract infection.
30. Having considered the evidence available, we think the Trust diagnosed Mrs D’s AKI at the earliest opportunity.
31. The adviser explained that although Mrs D’s CRP pre-discharge was raised at 70 mg/L (the normal range is 0-5 mg/L), at the same time her procalcitonin was near normal at 0.15 ng/Ml (normal range is 0-0.5 ng/mL). This suggests there was no bacterial infection.
32. CRP can be raised due to bacterial infection or several other causes (such as inflammation, recent surgery, viral infection etc.). Procalcitonin is more specific for bacterial infection and if normal, is suggestive that the CRP is high due to a different cause. This was the situation in Mrs D’s case.
33. Our physician adviser said it is important to note that blood tests are used in conjunction with clinical findings and other investigations. Blood tests cannot be interpreted in isolation. Also, in older people with multiple additional medical problems, blood tests can be less reliable and should be interpreted with caution. They said doctors would not use blood tests alone to determine management of a patient.
34. In this instance, Mrs D had no clinical signs suggestive of urinary tract infection prior to her discharge from hospital, and blood tests did not support the presence of a bacterial infection either.
35. We know Miss D was very concerned about the urine drained from her mother following her final readmission on 28 October and that this indicated a significant infection. By this point the doctors had reached the view that Mrs D was at the end of her life (we address this further from paragraph 108). Our physician adviser confirmed testing of urine when a patient is felt to be dying is not appropriate as it would not change the management.
36. We do not find there was a delay in the Trust diagnosing urosepsis.
Standard of nursing care
37. Miss D says a poor standard of care, following her mother’s readmission in September, put her mother at risk of infection. In particular, she is concerned her mother was left in soiled pads, developed pressure sores, her hydration and nutrition needs were not met, and the contents of her catheter bags were not checked for infection. She also says there was a lack of infection control procedures in place to minimise the risk of her mother catching COVID-19.
38. The Trust has accepted some failings in the nursing care it gave Mrs D, has apologised and outlined some action taken.
39. Our NHS Complaint Standards say organisations should give open and honest answers and should set out if any mistakes were made. The standards also say organisations should make sure any learning is identified and their staff should give sincere apologies.
40. With this in mind, we have considered if the Trust has appropriately acknowledged all failings in the areas of nursing care Mrs D raised and if it has appropriately addressed these. We asked our nursing adviser about this to help us determine if there are any aspects Miss D raised that the Trust has not already acknowledged. This has taken into account the standard of care the Trust should have provided, what the evidence in Mrs D’s records shows, along with the complaint correspondence.
41. We acknowledge Mrs D was in hospital during the COVID-19 pandemic. The Trust has explained staff were under immense pressure, with staff absent due to illness or because they were isolating. This does not excuse poor practice but gives context to the situation at the time.
Repositioning, continence and pressure area care 42. Miss D complains she had to ask staff to help reposition her mother and found her mother to be often unclean and left lying in a soiled incontinence pad. The Trust has said a shortage of staff on some occasions meant four-hourly checks were not always carried out on time. This meant there were sometimes delays in repositioning Mrs D and in providing continence care.
43. NMC standards ‘The Code. Professional standards of practice and behaviour for nurses, midwives and nursing associates’ tells nursing staff to ‘deliver the fundamentals of care effectively’ and to ensure ‘any treatment, assistance or care for which you are responsible is delivered without undue delay’. Bowel and bladder care, personal/hygiene care and physical handling are all part of the fundamentals of care.
44. The records show the Trust provided continence care and assisted Mrs D with her hygiene needs on a daily basis. The records show us ward staff checked Mrs D frequently, but they do not tell us if the assistance was provided at the time she needed it.
45. For example, on 26 October, the records show the ward staff checked if Mrs D needed to use the toilet on 12 occasions throughout the day, which is more often than every four hours. However, there was a gap between 2.51pm and 7pm when the staff did not document a check. We do not know what Mrs D’s needs were during this time.
46. The records also show staff frequently repositioned Mrs D. Typically, this was documented approximately every two hours, but occasionally happened more or less frequently. We saw on 27 September, 14 and 15 October a gap of just under five hours in the ward staff repositioning Mrs D. On 6, 8 and 18 October where there was a gap of just over five hours. On 7 October it took staff just over seven and a half hours to reposition Mrs D between 7.23am and 2.56pm. The records do not provide a reason for these delays.
47. We know Miss D is concerned her mother developed pressure sores to her sacrum, heels and toes following her readmission in September. In her account she describes having to ask ward staff to help reposition her mother every day. The Trust has acknowledged Mrs D developed pressure sores while she was in its care and has said it is likely exposure to moisture, due to her incontinence, contributed to this. It has also explained there were a number of other factors that meant she was unfortunately at high risk of developing pressure sores.
48. Repositioning is an essential part of pressure area management, as set out in guidance from NICE, ‘Pressure ulcers: prevention and management’. This states adults at high risk of pressure ulcers should be encouraged or helped to change position at least every four hours. It also recommends the use of a barrier cream in patients at risk of developing a moisture lesion, and the use of pressure redistribution devices, which includes specialist mattresses. It says patients with heel ulcers should have a strategy in place to offload the pressure from the heels.
49. Individualised care planning is a key part of pressure ulcer prevention under the NICE guidance. Having reviewed the Trust’s records, it is unclear how it planned to manage Mrs D’s risk of pressure sores, or how it planned to care for her when they developed. The records provided suggest a lack of consistency in how nursing staff provided pressure area care for Mrs D.
50. The Trust said in its second complaint response that it applied barrier cream throughout Mrs D’s admission. The records we have been given do not confirm this. There are many occasions when the records suggest the care provided was not in line with the NICE guidance.
51. The records show nursing staff first noted a concern with Mrs D’s skin on 26 September, when they documented her left heel was slightly red. In response, they recorded they had elevated it off the bed. A nurse noted redness to the left heel again on 30 September and said they had requested a heel protector.
52. The following day another nurse noted Mrs D’s red heel and documented that a ‘repose boot’ had been ordered. This is an inflatable device that relieves pressure from the heel. There is no subsequent record of a heel protector/repose boot being in use. Miss D has also told us she never saw any devices in use.
53. The next concern documented in relation to Mrs D’s skin was on 4 October, when a moisture lesion to her heels is noted. The nurse documented they had repositioned Mrs D. No other intervention is noted. Nursing staff noted the moisture lesion again on subsequent days but no specific actions are noted. On 12 October the occupational therapist recorded they left Mrs D with her heel raised off the bed.
54. On 13 October, a nurse has documented a moisture lesion to Mrs D’s sacrum, in addition to the one on her heel. They did not document any action taken. The same is noted on 14 October. On 15 October a nurse documented they had applied barrier cream to Mrs D’s sacrum. On 16 October a nurse recorded they had checked Mrs D’s pressure areas (noting the moisture lesions) but did not note any action taken. No action has been documented on 17 or 18 October.
55. On 19 October a nurse noted Mrs D had two lines of pressure area on her right big toe, from her foot being on the mattress pump brackets. They said the matron was aware and they had applied barrier cream. The moisture lesions were noted on subsequent days up to when the Trust discharged Mrs D but no action was noted.
56. We note when the Trust readmitted Mrs D on 28 October she had skin damage to her left heel and big toe, with a suspected deep tissue injury. Her sacrum was noted to be intact but with evidence of a previous wound.
57. Our nursing adviser has confirmed Mrs D’s frailty, immobility, low body mass index and incontinence meant there was a high likelihood of her skin breaking down. Even with appropriate care, this may not have been entirely preventable.
58. The adviser said Mrs D needed pressure offloading from her heels from 26 September when her left heel was noted to be red. There is no evidence that this consistently occurred. The adviser could not say this would have prevented the pressure ulcer, however, they said it is likely that with regular pressure offloading, a deep tissue injury would not have occurred.
59. We can see that inadequate continence care and repositioning is also likely to have contributed to Mrs D’s skin breakdown and overall discomfort.
60. We have considered if Mrs D’s skin damage could have contributed to her decline. Our adviser said given Mrs D’s severe frailty, COVID-19 infection and a suspected underlying malignancy, it was not possible to say the skin damage contributed to this. However, the skin breakdown would have been uncomfortable for Mrs D and we know this caused upset and distress to Miss D.
61. We appreciate it is very distressing for Miss D to know there were times when her mother did not get all the support she needed in hospital. She has described how traumatised she has been by her mother’s experience at the end of her life and the huge impact this has had on Miss D’s life.
62. We conclude there are failings in the pressure area care (which includes continence care and repositioning) the Trust gave Mrs D, which is likely to have impacted her and Miss D.
63. The Trust said it had reminded staff to be vigilant for patients who needed to be repositioned and to provide help with patients’ toileting needs regularly and as quickly as possible.
64. We do not consider the Trust has adequately addressed its failings in the pressure area care it gave Mrs D and recommend it takes further action about this. This is to recognise the distress the failings caused Miss D and to make sure improvements are made to prevent other patients having a similar experience. Our recommendations are set out at the end of this document.
Nutrition and hydration 65. The Trust identified nursing staff did not consistently complete nutrition and hydration charts, which meant it was difficult to build an accurate picture of what Mrs D was consuming and her fluid balance. We know Miss D was particularly concerned about her mother’s oral intake and, when allowed (under COVID-19 restrictions), would assist her mother at mealtimes.
66. The Trust also apologised for not having given Mrs D the supply of Lucozade Miss D had provided while she could not visit. It could not explain why staff did not give Mrs D the drinks and said it had given feedback to the ward team about this.
67. NMC standards ‘Future nurse: standards of proficiency for registered nurses’ say nurses’ responsibilities include optimising nutrition and hydration status, determining the need for intervention. NMC standards ‘The Code’ tell nursing staff to recognise and work within the limits of their competence, and this means asking for help from suitably qualified professionals when required. Trust staff appropriately recognised Mrs D needed specialist input from a dietician.
68. The records show Mrs D was referred to the dietician during her July admission, who gave advice. The dietician was involved again soon after Mrs D’s readmission on 20 September 2021. They reviewed her regularly until she was discharged and gave advice on how to improve her oral intake.
69. We noted the dietician repeatedly asked for nursing staff to weigh Mrs D and highlighted that the nursing staff had miscalculated her MUST score (malnutrition universal screening tool, a method for identifying patients who are malnourished or at risk of malnutrition).
70. Additionally, the dietician asked nursing staff to keep daily food/fluid charts and they noted nursing staff did not always complete these. So although the ward staff sought the dietician’s advice, they did not then do all that the dietician asked. This is not in line with the NMC standards. This is a failing.
71. Our nursing adviser clarified that both the correct and incorrect MUST scores identified Mrs D was at high risk of malnutrition. Therefore, we can reassure Miss D that the miscalculation of the MUST score was not harmful to her mother as the advice would have been the same. Additionally, the failure to record Mrs D’s weight and to keep accurate food/fluid charts did not prevent the dietician from giving appropriate advice.
72. The Trust has already acknowledged it did not always complete Mrs D’s food and fluid charts, making it difficult to gauge her intake. However, it has not recognised the feedback the dietician gave in the records about weighing Mrs D, or the miscalculation of her MUST score, or taken any action to address this.
73. NMC standards ‘The Code’ say nurses should ‘gather and reflect on feedback from a variety of sources, using it to improve your practice and performance.’ In line with this, we think the staff caring for Mrs D should have seen the dietician’s comments and acted on them at the time. It is a failing this did not happen.
74. We can see from the hospital records Miss D supported her mother at mealtimes and played a significant role in encouraging her mother to eat and drink. Miss D was understandably concerned ward staff would not support her mother to eat when she was not permitted to visit.
75. The records confirm nursing staff continued to provide support at mealtimes when Miss D was not there. The dietician’s records for the days Miss D could not visit show the nursing staff assisted Mrs D and she would eat a few mouthfuls then refuse anything further. The dietician was also satisfied nursing staff were giving Mrs D the nutritional supplements they had prescribed.
76. We can also see from the fluid balance charts that Mrs D was having some oral intake. The records also show nursing staff regularly checked Mrs D had a drink available.
77. Our nursing adviser said the actions taken to support Mrs D’s intake were appropriate. Unfortunately, despite this, Mrs D’s intake was poor.
78. Our nursing adviser said it is likely this reflected the natural decline in desire for food and drink as Mrs D was nearing the end of her life. Although there are failings in how the nursing staff responded to the dietician’s advice, we find this did not negatively impact Mrs D.
79. Nevertheless, we know Miss D was very concerned about mother’s nutrition and hydration. Her fears would have been confirmed when the unused drinks she provided were returned to her when her mother was discharged on 27 October. Although the Trust has apologised to Miss D for this, it has not taken action to address the failings we have identified. We are recommending the Trust takes action to put this right.
Infection control 80. Miss D complains there was a lack of cleanliness in the Trust, including soiled bed linen left on the floor, which she says put her mother at risk of infection. The Trust agreed it was not acceptable to leave soiled linen on the floor and said it would remind staff to follow its protocols.
81. We cannot account for the different practice Miss D observed in different parts of the hospital regarding the use of curtains.
82. It is difficult to gauge how well a Trust manages infection control from patient records. The Trust has explained its infection control measures in its responses. Our nursing adviser confirmed the measures outlined were in line with infection control procedures for the prevention of COVID-19 spread. The Trust are correct in saying that these guidelines changed rapidly in 2021.
83. We think the Trust has sufficiently addressed the problem Miss D raised.
Discharge on 27 October
84. Miss D says the Trust should not have discharged her mother on 27 October as she was too unwell. She believes her mother had been on intravenous (IV) fluids up to this point so questions how she could be expected to survive without these. She believes her mother had urosepsis and AKI at this point and highlights that the Trust failed to monitor her fluid input and output prior to discharge so says the Trust cannot support its claim she was 'medically optimised'.
85. Miss D had not been able to visit her mother leading up to the discharge as Mrs D had COVID-19 and describes how shocked she was at her mother's poor condition on returning home. Mrs D was returned to hospital the following day due to the concerns of healthcare professionals.
86. Miss D also complains the Trust discharged her mother with medication she was unable to take, with no advice and no discharge summary. The Trust has acknowledged and apologised that it did not provide a discharge summary.
87. The Department of Health policy ‘Hospital Discharge and Community Support: Policy and Operating Model’ says people should be discharged from hospital as soon as they no longer need to remain in an acute bed. It says they should have their ongoing needs assessed in the community. It says people should be discharged when they are ‘medically optimised’ but does not specify what this looks like.
88. Mrs D’s medical records show the medical team reviewed her daily in the days leading to discharge. This included the consultant reviewing her on the day of discharge. They considered Mrs D was medically suitable for discharge home.
89. Our physician adviser said there were no indicators of concern from the clinical reviews or Mrs D’s national early warning score (NEWS). This is a system for monitoring the risk of deterioration in a patient, calculated from their vital signs (heart rate, breathing rate, blood pressure, temperature etc.).
90. The records show Mrs D had been on IV fluids for two days to support her blood pressure, which had been noted to be low. Low blood pressure can be caused by a low volume of plasma in the blood (known as hypovolaemia). NICE guidance ‘Intravenous fluid therapy in adults in hospital’ recommends IV fluids to correct this and states fluids should be stopped when no longer required.
91. At the ward round on the morning of 25 October, Mrs D’s blood pressure had returned to normal and the consultant decided the IV fluids could stop after the current bag has finished, in line with the NICE guidance. The doctors reassessed Mrs D’s blood volume at subsequent ward rounds on 26 and 27 October and documented that this was normal (euvolemic).
92. According to the medical records, Mrs D’s oral intake was improving, there were no surgical concerns following her recent hip surgery and blood tests on 25 October 2021 did not raise any concerns.
93. Our physician adviser confirmed the information in the medical records shows it was appropriate for the Trust to discharge Mrs D. We acknowledge Miss D’s strength of feeling that this was not the case, particularly as Mrs D needed to be readmitted soon after. This does not lead us to conclude the Trust was wrong to discharge her.
94. We are satisfied the Trust acted in line with the Department of Health policy.
95. We find no failings in the Trust’s decision to discharge Mrs D on 27 October.
Discharge medication 96. In relation to the medication the Trust sent Mrs D home with, Miss D has provided photographs of the items the Trust sent her mother home with. The items do not fully match the ‘to take out’ (items patients are given on discharge from hospital) dispensing form dated 26 October 2021 in Mrs D’s records.
97. The dispensing form for 26 October shows the Trust prescribed four medications:
• senna tablets (a treatment for constipation), to be taken once a day • Adcal-D3 chewable tablets (a calcium and vitamin D3 supplement), to be taken twice a day, and • macrogol compound oral powder sachets (a treatment for constipation), which are dissolved in water and taken twice a day as needed • tinzaparin (a blood thinning medication given by injection).
98. In addition to these, Mrs D took home: • carbocisteine (a medication that helps thin and loosen mucus in the lungs) • Relaxit (an enema to soften hardened stools) • furosemide (a medication that removes excess fluid in the body. It is also used to treat high blood pressure and heart failure) • colecalciferol (a type of vitamin D).
99. The medications the Trust gave Mrs D to take home also included duplicates of some items: tinzaparin injections, furosemide and senna.
100. We asked the Trust about the discrepancies. It could not say exactly why this happened and offered several possibilities including an error on the ward or in the pharmacy. It also located an earlier ‘to take out’ dispensing form, dated 6 October. Mrs D was not discharged on or around this date. This form includes furosemide and colecalciferol, so accounts for some of the items not on the 26 October form. It does not account for the carbocisteine or Relaxit.
101. According to the entries in the records, the medical team decided to suspend furosemide on 22 October as Mrs D’s blood pressure was low. There is no record the doctors decided to restart it prior to Mrs D’s discharge. The pharmacist on 26 October has noted the furosemide was suspended, which would explain why it was not included on the 26 October form.
102. The pharmacy records also show colecalciferol was prescribed as a 14 day course and stopped on the ward on 7 October. There is no indication it was restarted.
103. It is unclear why the medications Mrs D left hospital with on 27 October do not match those on the ‘to take out’ dispensing form for 26 October and include items Mrs D was no longer taking.
104. We think there is a failing in the Trust’s process for making sure patients are sent home with the correct medication.
105. Miss D says the oral medication was unsuitable because her mother was too unwell to take the medication. Prior to discharge, Mrs D had been on a normal diet and there were no concerns about her ability to swallow medication. There is no indication she needed medication in liquid form, so the format prescribed was appropriate.
106. Miss D says they had no instructions on dose/timing as there was no discharge summary. Our physician adviser clarified that hospital pharmacy teams do not rely on the discharge summary to prepare medication for patients to take home on discharge. The absence of a discharge summary should not mean there was no information to guide how the medication should be taken.
107. Instead, the instructions for dose/frequency are normally found on the medication packaging, along with the patient’s details. Miss D has confirmed the packaging includes this information. We hope it will reassure Miss D to know that our physician adviser said Mrs D would not have come to harm by not taking the medication.
108. In addition to oral medication, the Trust prescribed tinzaparin, which is given by injection. This was to prevent blood clots while Mrs D’s mobility was reduced and following her COVID-19 infection. This was to be injected once a day. According to the prescription record for 26 October Mrs D needed a final dose on 28 October, having been given the medication in hospital since her surgery. It is unclear why the Trust gave Mrs D two boxes to take home, each containing several injections.
109. Miss D says the Trust provided no information to her or her mother’s carers about this, and also sent her mother home with some oxygen tubes, again without any information.
110. We cannot provide any clarification on the oxygen tubes as there is nothing about this in Mrs D’s records or the Trust’s responses. These appear to have been sent in error.
111. Tinzaparin injections need to be given just under the skin. Patients can be shown how to do this before they leave hospital, but given Mrs D’s frailty and her known care needs on discharge, there is no indication the Trust had expected her to inject herself. Sometimes family members are shown how to administer the injections and are happy to do this. We know this did not happen here as Miss D had not been allowed to visit her mother in the period leading up to her discharge.
112. Instead, the Trust should have checked that someone was able to administer the injections. There is no evidence this happened, which is a failing. Our nursing adviser said it could not be assumed that the carers would administer them. Sometimes district nurses are required to give the injections, which would have required the Trust to make a referral. This should have been established prior to discharge.
113. NMC guidance ‘The Code’ tells nurses to ‘make a timely referral to another practitioner when any action, care or treatment is required.’ We have seen no evidence this happened. This is a failing.
114. The Trust said in its response of 17 March 2023 that ward staff had handed Mrs D’s medication to the ambulance team who took her home. The ambulance crew would not be expected to explain what medication a patient needs on discharge from hospital and would not have any role in demonstrating how to administer a tinzaparin injection or arranging for this to be done. This was the Trust’s responsibility.
115. We know Mrs D did not come to any harm from not receiving the tinzaparin injections on discharge from hospital, as she did not develop any blood clots. Mrs D also did not come to harm from the errors with her discharge medication. Nonetheless, we can see it was upsetting and frustrating for Miss D and will have added to her loss of faith in the Trust.
116. We are making recommendations to the Trust in recognition of the upset it has caused Miss D and to improve its service.
Decision that Mrs D was at the end of life
117. Miss D says the Trust inappropriately decided her mother was dying of COVID-19, when previously it said she was asymptomatic and had been considered well enough to be discharged from hospital on 27 October.
118. The ‘Learning from Deaths’ report found the Trust prematurely decided Mrs D was at the end of life, instead of looking for a reversible cause of her decline.
119. We noted the medical examiner and ‘Learning from Deaths’ report concluded urosepsis caused Mrs D’s death, rather than frailty as had previously been stated. The Trust appears not to have accepted the ‘Learning from Deaths’ report and said it was written in hindsight. It maintains Mrs D was at the end of life.
120. We considered if the evidence available shows the Trust reached appropriate conclusions about the cause of Mrs D’s deterioration on readmission.
121. NICE Guideline 31 ‘Care of dying adults in the last days of life’ sets out recommendations for healthcare professionals who consider a patient may be approaching the end of their life. It acknowledges it can be difficult to be certain if someone is dying. It includes the signs that indicate a person is likely to be at the end of life and makes recommendations for the care given. This includes that investigations should be avoided if they are unlikely to affect the last days of life.
122. Professional standards guidance from the GMC ‘Treatment and care towards the end of life: good practice in decision making’ tells doctors to give ‘careful consideration of the patient’s clinical situation’ and to ‘carry out a thorough assessment of the patient’s condition and likely prognosis’.
123. The entries in the records show this is what happened.
124. The doctor who admitted Mrs D was a registrar (a senior and experienced grade of doctor). Their impression was that she was likely to be approaching the end of life. Our physician adviser said there were many factors supporting that assumption.
125. The physician adviser explained the available medical records outline a lady who was severely frail, with very poor physiological reserve (the body’s ability to respond to stressors, such as illness, beyond everyday functioning), and significant pre-existing medical conditions.
126. These included severe aortic stenosis (a serious condition where the main outlet valve of the heart is severely narrowed) and ischaemic heart disease (where the heart’s arteries become narrowed due to fatty deposits, which can restrict the supply of blood to the heart). Additionally, Mrs D had spent many weeks in hospital on two recent admissions and was admitted for a third time.
127. They also noted the nursing and medical notes describe Mrs D as being distressed at times and give the impression Mrs D was suffering. This is echoed in discussions hospital staff had with Miss D.
128. Mrs D went from being assessed in the emergency department, to having a more detailed assessment by a registrar from the medical team. They also discussed their view with Miss D. A consultant and another junior doctor then reviewed Mrs D the following morning. The consensus view from those opinions was that Mrs D was sadly at the end of life.
129. The NICE and GMC standards reflect that deciding someone is at the end of life is a difficult decision to make, and if there is uncertainty it is reasonable to start treatment and review. The Trust did this as it continued to treat Mrs D with IV fluids for her acute kidney injury (AKI) until it had reassessed the clinical situation the morning after admission.
130. Our physician adviser explained the AKI was part of a bigger clinical picture which reflects that Mrs D was very frail, unwell and approaching the end of life. She had a stage one AKI, which could have been caused by infection, dehydration or just part of her general decline.
131. Our physician adviser explained in this situation a label of AKI does not tell us anything meaningful about the patient’s condition. This means the medical team would not focus on AKI on its own, but would look at the overall picture.
132. The team stopped the IV fluids once it determined Mrs D was at the end of life. This is in line with the GMC guidance on treatment towards the end of life, as it is unclear if such an intervention is beneficial, or if it prolongs the dying process.
133. We saw the ED doctor also started Mrs D on IV antibiotics. Our physician adviser explained this was because they were following sepsis guidelines from NICE (NICE Guideline 51, ‘Suspected sepsis: recognition, diagnosis and early management’), which says that if sepsis is a possibility, IV antibiotics should be given within an hour.
134. Our adviser explained the ED team do not have much time to assess a patient and then start antibiotics, whereas the medical team were able to make a more considered judgement based on the clinical picture over the next day or so. Based on this they decided not to continue antibiotics as Mrs D was at the end of life.
135. We saw the decision to move to end-of-life care was consultant-led but also discussed and explained to Miss D.
136. NICE guidance on ‘Care of dying adults in the last days of life’ and the GMC professional standards recognise the importance of supporting those close to the patient. There is evidence the team involved Mrs D’s daughter and she was in agreement with the plan to manage her symptoms.
137. The records by members of the medical team and the palliative care team outline frank discussions with Miss D that her mother was likely to be approaching the end of life. The records give the impression that the joint goal between Miss D and the multidisciplinary team was on maintaining Mrs D’s comfort and alleviating suffering.
138. The Trust’s ‘Learning from Deaths’ report, which raised the possibility the Trust had prematurely concluded Mrs D was at the end of life, appears to have cast doubt on what should have happened.
139. For context, our physician adviser explained that unfortunately, medical reviewers used for ‘Learning from Deaths’ reports may be from any medical or surgical specialty background. They may not be experts in the field they are reviewing and may not be specialists in recognising and managing end of life situations in complex frail patients. They said it is therefore understandable how this situation has occurred.
140. We asked our physician adviser about the Trust’s assumption Mrs D’s deterioration was due to COVID-19. They explained COVID-19 in older people is associated with general symptoms of illness that include delirium and fatigue. They said the clinical records and blood results leading up to 27 October 2021 did not suggest any additional cause of deterioration, and it was reasonable to consider COVID-19 as a cause.
141. Our physician adviser also highlighted what the Trust said about it having missed an opportunity during Mrs D’s previous admission to recognise and acknowledge she was approaching the of her life. The Trust has recognised it needed to do more to recognise patients nearing the end of life. It said it was working to improve this area and apologised for Mrs D and Miss D’s experience.
142. NICE guideline 142 ‘End of life care for adults: service delivery’ sets out what service providers should do when they identify a patient is likely to be approaching the final weeks or months of life, and the plans that should be made around this.
143. Had the Trust recognised after Mrs D was readmitted in September that she was getting towards the end of her life, it may have allowed more detailed discussions to take place with Mrs D and her family about her wishes for her care, before an emergency situation arose.
144. However, we can appreciate why the Trust were focused on getting Mrs D home following her admission in September and did not identify she was dying until she was readmitted. We recognise Miss D was very upset by the Trust having identified this in hindsight, as it was too late to be of benefit to her mother. We know how important it was to Miss D for her mother’s wishes to be carried out.
145. In summary, the entries reflect that Mrs D was very frail, was distressed following the readmission, was declining and at the end of life. Managing her symptoms palliatively was appropriate and supported by the GMC and NICE guidance. We have identified no failings in how the Trust acted.
‘Learning from Deaths’ report
146. Miss D complains the Trust has not accepted its own ‘Learning from Deaths’ report, which identified problems with her mother’s care. The report found the Trust prematurely decided Mrs D was at the end of life, instead of looking for a reversible cause of her decline.
147. ‘Learning from Deaths’ is a framework for NHS Trusts and NHS Foundation Trusts to identify, report, investigate and learn from deaths in care, based on guidance from the National Quality Board. The investigations are intended to be used within the organisation for learning and be acted upon. In addition, Trusts are required to collect and publish specified information from the process.
148. In this case the report outlined that the care would be discussed at an Executive Review meeting, the learning points identified and taken back to the emergency department and the ward. We acknowledge the Trust ultimately reached a different conclusion to the report author, as have we. However, it has still identified learning from Mrs D and Miss D’s experience and sought to improve its service in light of this.
149. It is regrettable the report caused Miss D to question the decisions the Trust made about her mother’s care. We can understand why Miss D is concerned that the Trust’s complaint responses differ to the ‘Learning from Deaths’ report. That said, as we have found Mrs D was sadly dying following her readmission to hospital on 28 October, we do not criticise the Trust for not having accepted the report findings.
150. Miss D also feels the Trust has directed her down the wrong path by going through the ‘Learning from Deaths’ process and is concerned her mother's death should really have been reported to the coroner.
151. The joint guidance for doctors on completing medical certificates of cause of death (MCCD) says the doctor who attended the patient in their last illness should issue the cause of death certificate. Where the patient died in hospital, it is the responsibility of the consultant in charge of the patient’s care to ensure the death is properly certified.
152. Deaths only need to be reported to the coroner in specific instances, such as when the death is unnatural or the cause unknown. The guidance says deaths that may be due to neglect should also be referred.
153. Beginning in 2019, the NHS began to roll out a new system in acute trusts, to provide independent scrutiny of all deaths in hospital. The ‘National Medical Examiner’s good practice guidelines’ (January 2020) say the scrutiny must involve:
• a review of the medical records • a review of the proposed cause of death and whether the coroner needs to be notified, and • asking the bereaved if they have any questions or concerns.
154. The guidelines say the qualified attending practitioner (the doctor responsible for completing the MCCD) should form their own view before discussing the case with the medical examiner.
155. We can see this process was followed in Mrs D’s case. The records show the medical examiner reviewed Mrs D’s full clinical records and spoke to Miss D to understand her concerns. Following this, they suggested urosepsis be added as the main cause of Mrs D’s death, because of the appearance of the urine drained when she was catheterised. They were satisfied there were no grounds to refer Mrs D’s death to the coroner.
156. The guidelines also say medical examiners have important links to the Learning from Deaths system and are required to highlights cases that require review. We can see the medical examiner did this.
157. We are satisfied it was appropriate for the treating doctor and medical examiner to issue a cause of death, and that there was no need to refer Mrs D’s death to the coroner. We have identified no failings here.
158. We hope our explanations will give Miss D some reassurance about what happened.
Errors in the complaint responses 159. Miss D says the Trust repeatedly made mistakes in its responses when referring to key dates, including the date her mother died. She says even after she raised this with the Trust and it apologised, it made the same mistakes again.
160. Having reviewed the Trust’s responses, we have not found any occasions when it gave incorrect dates for any significant events, including the date of Mrs D’s death, her admission or discharge dates. We found no evidence that Miss D raised this with the Trust or that it had apologised for any errors with dates.
161. We saw one instance when Miss D had reviewed her mother’s hospital records and said a reference to the number of weeks her mother had been in the nursing home was incorrect and some dates of care plans were wrong. This did not relate to what the Trust had said in its response and therefore appears unrelated to the issue Miss D has complained to us about.
162. We have not identified any errors with dates in the Trust’s responses as Miss D has indicated.