20. When we consider complaints about clinical care, we consider what should have happened based on the guidelines and information the clinicians had available to them at the time the events took place. Sometimes, more information can come to light at a later date that can, with hindsight, change the clinical picture. We can only consider what the clinicians knew at that time, and which guidelines should have been followed based on what was known when the Trust made important decisions.
21. In this case, we know Mr O died from sepsis. Our adviser explained that his documented clinical presentation was not typical for a person with an active infection and sepsis. We must ensure that our decision about what should have happened at that time is not unfairly or unreasonably directed by any information that became available after these events took place.
Bank holiday care
22. The Royal College of Physicians’ published guidelines for safe medical staffing, which includes what care should look like at times of reduced staffing, recognises that on weekends and bank holidays the staffing levels are usually significantly reduced. It has produced guidance on what safe medical care looks like at times of reduced staffing.
23. These guidelines outline that basic aspects of care should remain the same at weekends and on public holidays. They say that daily reviews from a consultant, and interventions and investigations should still happen unless these are unlikely to affect the direction of a patient’s care.
24. The guidelines outline three tiers of medical care for weekends and public holidays:
• Normal care –care should progress as normal through the weekend. The guidance states that whilst the same standard of care as on any other day of the week would be ideal, there is no prospect of support services in hospital being able to provide this • Emergency care – this is typical of the weekend care currently provided in many hospitals. The lower staffing levels mean fewer patients are discharged and care progresses more slowly • Best practicable care – a standard of care that requires an appropriate level of medical staffing, greater provision of imaging, and provision of services to support discharge patients to the community.
25. The guidance recognises most hospitals provide care that is somewhere between emergency care and best practicable care. This means that, in practice, the Trust would not be expected to provide the same level of day-to-day care if Mr O was clinically stable, but should still have acted on anything that affected the direction of his care or required emergency intervention.
26. Mr O was admitted to hospital on 25 May, which was a Thursday. The bank holiday weekend commenced on 27 May until 29 May.
27. On 27 May, Mr O had blood tests, was reviewed by the nursing team, and was reviewed by a Senior House Officer (SHO). An SHO is a resident doctor with between two and four years’ post-qualification experience. His notes indicate care continued broadly as normal, with discharge planning and consultant review not occurring most likely due to the staffing constraints of a weekend.
28. On 28 May he was assessed by the Occupational Therapy (OT) team with a view to facilitating his discharge home. Standard nursing care continued, and Mr O was reviewed again by an SHO. The SHO decided not to discharge him that weekend and to keep him in hospital for imaging due to continued lumbar pain. The SHO also recommended a urine dip screen to check for signs of a urinary tract infection, which happened and returned a negative result.
29. On 29 May he was reviewed by an F2 resident doctor, which is a doctor who is in the second year of their post-qualification training. This doctor reviewed his care via a discussion with the radiology team. Mr O’s nursing care was provided as normal.
30. The Trust appears to have been providing care that aligned with the ‘best practicable care’ tier as outlined in the guidance. It appears to have provided care that went above emergency care only; however, it was not fully in line with what would be expected on a weekday because there was no consultant review every 24 hours.
31. As there were no changes in Mr O’s clinical condition that would indicate the direction of his care pathway needed to change, the evidence indicates his care over that weekend aligned with the Royal College of Physicians’ guidelines on safe medical staffing. This is because he was reviewed by a doctor each day, nursing care was provided, and additional interventions such as imaging referrals were also completed. There is also evidence of multidisciplinary input from the OT team over that weekend.
32. Whilst providing the same level of care as a weekday would be ideal, the guidelines recognise that for most hospitals this is not possible. As the care provided appears to align with the standard outlined for weekends and bank holidays in these guidelines, there are no indications of service failure.
Care pathway and transfer
33. The GMC’s Good Medical Practice guidelines say that doctors should promptly provide or arrange suitable advice, investigations, or treatment where necessary.
34. On 26 May a consultant reviewed Mr O and set out a plan for the weekend which was to:
• continue administering furosemide (antidiuretic medication) • maintain a fluid intake/output chart • refer for review by heart failure team • daily monitoring of U&Es • if pain continues, clarify source of pain • transfer to the hospital’s cardiology ward.
35. The plan from the consultant was updated that day, and no longer included the transfer to the Trust’s cardiology ward. This was following the review from the Trust’s heart failure service that concluded his primary health needs were not cardiological in nature, and that his cardiology care could be managed in the community.
36. Following this plan being documented, the nurses commenced fluid balance charts, which were maintained daily by the nursing team. His IV furosemide was stopped by the specialist heart failure team on 26 May but was given as prescribed up until that point. The doctors also documented discussions about imaging to discover source of his lumbar pain, in line with the plan.
37. His daily U&Es were not completed over the weekend. He was also transferred to a different ward than initially recommended by the consultant. Our adviser explained that this ward was more likely than not better suited to his needs than a cardiology ward and would have had the equipment and expertise required to provide the care Mr O needed.
38. The evidence indicates that the Trust followed the plan documented by the consultant for the bank holiday weekend, aside from undertaking daily U&Es. This was a shortfall in his care. Had these tests taken place it is unlikely it would have changed the course of his treatment over that weekend. This is because these blood tests could not have alerted the doctors to the potential presence of an infection. They could only indicate Mr O’s kidney function, which remained stable according to the test results from 30 May.
39. On balance, the failure to complete daily U&Es appears to fall short of completing the plan set out by the consultant that weekend. We do not think this fell so far short of the GMC’s Good Medical Practice guidelines that it could amount to service failure. This is because, when we balance the evidence, the majority of the plan was followed and this oversight more likely than not had no impact on the direction of his care.
Blood tests
40. The plan from the consultant was to monitor Mr O’s U&Es over the weekend via daily blood tests. His CRP (indicator of inflammation) and white cell count were within normal ranges when his full blood count was done prior to that weekend. As there was no instruction from the consultant to repeat the full blood count over the weekend, the Trust only needed to do this if there was a clinical change that indicated this should happen.
41. NHS hospitals in England use the NEWS2 tool to monitor patients for signs of deterioration. This tool was developed by the Royal College of Physicians, which also publishes guidance on how to use it.
42. NEWS2 requires clinicians to monitor patients’ physical observations and use these results to calculate a score. This score tells clinical staff how they should respond to a patient’s condition. The guidance published alongside the NEWS2 tool states that ward-based care should continue for patients with a score under five. Similarly, the Royal College of Physicians’ guidance on safe staffing levels also says the threshold for escalating care at a weekend is a NEWS2 score of five or above. The NEWS2 tool is also recommended by NICE guideline NG51 for monitoring patients’ risk of death from sepsis.
43. The NEWS2 score is the best evidence we have as to whether there was a clinical indication that further tests may be required, especially in relation to infection.
44. Mr O’s NEWS2 scores were stable, between zero and three, across the weekend. There was one set of observations where he had a slightly raised temperature of about 38.5°C on 28 May at 2am. However, by 6am this had returned to normal and there were no other abnormal observations or clinical concerns documented over that weekend.
45. NICE Guideline NG51 specifically states ‘do not use a person’s temperature as the sole predictor of sepsis’ and ‘do not rely on fever or hypothermia to rule sepsis in or out’. This means that a one-off spike in temperature would not have alerted the staff to a risk of sepsis without other clinical indicators. If this increase in temperature had been maintained or his NEWS2 score had increased in other areas, this should have prompted the nursing team to escalate his care to a doctor. This did not happen, and so there was no reason to take further action.
46. The evidence indicates that Mr O’s physical observations were stable over the weekend, and there were no consistent indicators of infection or any other reasons to request a full blood count. With hindsight, we know it may have been useful for this to have happened over the weekend, though we cannot know exactly when his CRP and white cell count began to rise. Based on the information available to the clinical team at that time, our adviser said it was clinically appropriate that the Trust did not request these blood tests over the weekend because there was nothing to indicate that Mr O’s condition had changed or that he may have an infection during this time. For this reason, we have seen no indications of service failure.
Monitoring
47. In line with the GMC’s Good Medical Practice guidelines, the clinicians should have ensured they took account of Mr O’s condition and history, and promptly arranged any suitable investigations or treatment as necessary. They should also have referred him to another clinician if this met his needs.
48. The Royal College of Physicians’ guidelines on using the NEWS2 tool state that patients should be monitored according to their level of clinical risk. This tool recommends monitoring patients every four to six hours when they have a NEWS2 score between one and four.
49. Mr O presented at the hospital with shortness of breath and fluid retention. He also had heart failure and kidney disease. On admission to the ED the Trust took a full history and examined Mr O. The Trust also undertook appropriate investigations, such as imaging and blood tests, and commenced appropriate treatment.
50. This process was repeated by the consultant on 26 May, the Trust made referrals to the heart failure team and the JET team, which helps patients to manage chronic health conditions in their own home.
51. The doctors continued to assess Mr O’s condition each day over the bank holiday weekend and arranged for investigations and treatment as required. For example, arranging for imaging to explore the reasons for his ongoing lumbar pain.
52. The evidence indicates the Trust’s doctors acted in line with the GMC’s Good Medical Practice guidance when assessing and monitoring Mr O.
53. The nursing team were also consistently monitoring Mr O’s physical observations throughout his admission and did so consistently within the four to six hour timeframe recommended for individuals with a NEWS2 score between one and four. There was nothing documented that should have caused the clinical team to reconsider the frequency of these observations.
54. The evidence indicates that doctors took account of Mr O’s medical history and planned his care appropriately based on the information they had, in line with the GMC’s Good Medical Practice guidelines. The evidence also indicates that he was monitored appropriately by the doctors and the nursing staff, in line with the NEWS2 guidance, during this admission.
Infection
55. We understand that Mr O’s cause of death was sepsis and that he died very suddenly. This understandably raises questions about whether this could have been identified sooner.
56. Our adviser commented that Mr O’s documented clinical presentation was unusual and not typical for a person with sepsis. This is an important observation because the actions taken by the Trust prior to Mr O’s death could only be informed by his clinical presentation at that time.
57. NICE Guideline NG51 says to suspect sepsis when people present with signs and symptoms of infection. This guidance recommends using the NEWS2 tool to assess people over 16 with suspected sepsis when they are in an acute hospital setting. These guidelines were updated in 2024, and we have used the 2016 version of these guidelines, which was the version in place at the time.
58. NG51 outlines the indicators of a patient being at high risk of severe illness or death from sepsis in section 1.4 of the guidance. It advises using patients’ physical observations to assess this. As per the guidelines, all of Mr O’s physical observations fell within the low-risk parameters for death from sepsis throughout his admission.
59. The 2016 guidelines only recommended taking action when a person may have an infection and met one or more of the high-risk criteria (as outlined in section 1.4 of the guidance). The national guidelines in place at that time did not inform clinicians what should happen if a person may have an infection and did not meet any high-risk criteria. This has since been updated in 2024, and the guidelines now cover what to do for low-risk patients. Unfortunately, this guidance was not in place at the time of Mr O’s admission and the clinicians had to rely on their clinical judgement.
60. Despite Mr O not meeting any of the high-risk criteria, when his full blood count indicated a possible infection a doctor escalated this to senior clinician. The senior clinician recommended taking blood cultures and prescribing antibiotics. This broadly aligns with the steps NG51 says should have been taken for high-risk patients, and this indicates that the doctor had used their clinical judgement to escalate Mr O’s care despite him not meeting the high-risk criteria. The guidance also recommends administering antibiotics without delay for those at high risk of death from sepsis.
61. There was a delay between the full blood count results coming back at 2.25pm, the discussion with the senior clinician at 2.55pm, and the administration of antibiotics at 5pm. The records indicate that Mr O was not on the ward between for at least part of this delay. This is because Mr O’s NEWS2 chart records he was not on the ward at 3.30pm. We know he had a lumbar X-ray at around this time, and the most likely explanation is that he was off the ward for imaging tests during at least some of the time between the decision to start antibiotics, and when they were administered. Unfortunately, the lumbar X-ray results do not tell us what time this took place, and his clinical notes do not reflect how long he was off the ward.
62. Mr O’s NEWS2 scores also consistently indicated he had a low risk of death from sepsis, with the scores being consistently between zero and three during his admission. The national guidelines provided no timeframe for administering antibiotics to patients who were low risk at that time.
63. The updated version of NG51, in place since March 2024, says that for those at low risk of death from sepsis, administering antibiotics can be delayed for up to six hours whilst undertaking further investigations. Whilst we cannot say the Trust should have followed guidelines that were not in place at that time, this does indicate that for individuals presenting as low risk it is usually safe for there to be some period of delay in administering antibiotics. Our adviser said the two-hour delay in this case is unlikely to have had any impact on the sad outcome.
64. In summary, there were no national guidelines for what to do when someone had indicators of infection but did not meet high risk criteria for sepsis at the time Mr O was in hospital. The Trust escalated Mr O’s care to a senior clinician and decided to commence antibiotics despite him not meeting the high-risk criteria in the guidelines. This went above what was recommended in NG51 at that time.
65. There was a two-hour delay between the advice from the senior consultant to commence antibiotics, and administration of the first dose. This was more likely than not due, at least in part, to Mr O not being on the ward during this time. There are no indications of service failure as the evidence does not suggest the Trust departed from the national guidelines in place at that time.
Complaint handling
66. Our NHS Complaint standards say that NHS services should: • embed an open, non-defensive approach to learning from complaints • create a positive experience by making it easy for service users to make a complaint • give an open and honest answer as quickly as possible.
67. They also say NHS services should give fair and accountable responses that set out what happened and whether mistakes were made.
68. The Trust held a meeting with Mrs A’s family on 3 October 2023. This meeting was the Trust’s final response on the matter and a written account of this meeting was sent to Mrs A on 27 February 2024.
69. Having reviewed the complaint response, we have seen nothing to indicate the Trust was approaching this defensively. The meeting transcript indicates the Trust was open and honest about what happened generally, though it does appear to have confused and incorrectly relayed some of the clinical facts of the case. This openness is indicated by the information related by the Trust, and that it appears to have taken time to explain medical jargon and concepts during the meeting. This indicates a level of transparency because it shows the Trust were trying to help the family understand what happened.
70. Overall, the approach in the meeting appears to have taken account of the family’s views and attempted to address them openly. Unfortunately, the Trust appears to have made mistakes and relayed some incorrect information to the family, which understandably caused concern and for them to lose faith in the Trust’s candour.
71. The main oversight, highlighted by our adviser, is that the account of what happened with regards to the timings of blood results. The information within the meeting minutes does not align with the medical records on this issue, and the action taken appears to have been incorrectly relayed to the family during this meeting. We have considered if this indicates a lack of candour on the part of the Trust.
72. We think this confusion most likely arose due to the way the medical records, which are currently a hybrid format, document the results and timings of laboratory results. It took us an unusually long time to establish what happened and at what time due to the format of the electronic laboratory records. We had to cross reference the analogue notes kept by the clinical staff with the timings in these electronic records to establish the most likely sequence of events. Having done so, this does not align with the Trust’s account of events in the meeting it held.
73. There is no objective evidence that the Trust was being deliberately dishonest when it incorrectly relayed these details. This discrepancy appears to have more likely than not happened due to of human error, rather than deliberate dishonesty. However, this still appears to fall short of accurately setting out what happened, and it prevented the Trust from providing an open and honest answer to this aspect of the complaint.
74. Whilst this error appears to fall short of our NHS Complaint Standards, when viewing complaint handling in the round we do not consider this could amount to service failure. We do recognise, however, that this mistake had a significant impact on Mrs A and her family, and we have asked the Trust to consider apologising to her for this error, and the impact it had.
75. We understand that this was an incredibly difficult and distressing experience for Mrs A and her family. We hope they are reassured that the clinical care provided to Mr O appears to align with the national guidelines in place at that time.