County Durham and Darlington NHS Foundation Trust

3. Mrs A complains about the care provided to her husband, Mr B, by County Durham and Darlington NHS Foundation Trust (the Trust) from 17 to 26 May 2022. Specifically:

• Mr B was pressurised into having an EBUS procedure on 24 May 2022 which he was unfit to have due to his stage 4 cancer, as well as having a temperature on the morning of the procedure and thrush in his mouth. Mrs A says her husband had to travel to another site to have the procedure when he just wanted to go home to be with his family instead of having the EBUS • After Mr B’s EBUS procedure, he suffered a marked deterioration in his condition on 25 May 2022 and sadly died the next day. Mrs A says that nursing staff never identified her husband’s deterioration, and it took a phone call from her on 25 May 2022 before any action was taken, but it was too late • Mrs A says her husband knew he was terminally ill with cancer and therefore he did not want any treatment. He wanted to be discharged from hospital, but his wishes were never taken into consideration by the Trust in accordance with his care plan and a Do Not Attempt Resuscitation (DNAR) order that was in place.

4. Mrs A and her family have struggled since Mr B died with the thought that he should have been discharged to home instead of being allowed to die in hospital which is not what any of them wanted. Mrs A has lost income since her husband died and has lost a considerable amount of weight due to the stress of these events. Mr B’s daughter had to have grief counselling due to these events and eventually lost her job. Mrs A says the trauma of what her family witnessed regarding Mr B’s care when he was in hospital will never leave them.

5. As an outcome, Mrs A wants further explanation about Mr B’s care alongside service improvements at the Trust regarding the way in which it manages the care of terminally ill patients. She also wants a financial remedy for the trauma these events caused her family.

6. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

7. Mr B was 65 years old with a clinical background of diabetes and stage 4 terminal lung cancer. On 17 May 2022, Mr B had an appointment with his lung specialist. Due to high blood sugar levels, he was admitted into Darlington Hospital, which is part of the Trust, that evening.

8. Over the next few days, Mr B was treated with insulin for his high blood sugar levels. His wife, Mrs A, says he was struggling with his toileting and wanted to come home, but the Trust felt he needed an endobronchial ultrasound (EBUS) procedure to help with his cancer treatment and pain relief. Mrs A says that Mr B and his family did not want him to have this procedure, but his blood sugar and potassium levels were still abnormal.

9. Mr B had his EBUS procedure on 24 May 2022 and was placed on a potassium drip. He was hoping to be discharged from hospital the following day, but the Trust said his oxygen saturation levels (SATS) on 25 May 2022 meant this could not happen. Unfortunately, Mr B became unwell later that day with a possible infection. An x-ray and CT scan showed he had a blood clot, and his family were told he was dying.

10. Mr B’s condition deteriorated further overnight. He was given pain relief and made comfortable, but he sadly died the following morning which was 26 May 2022. The cause of his death was pneumonia.

EBUS procedure

15. Mrs A says Mr B was pressurised into having an EBUS procedure on 24 May 2022 which he was unfit to have due to his stage 4 cancer, as well as having a temperature on the morning of the procedure and thrush in his mouth. Mrs A says her husband had to travel to another site to have the procedure when he just wanted to go home to be with his family instead of having the EBUS.

16. As regards Mr B having the EBUS, our consultant adviser says the relevant NICE guidance for managing patients with lung cancer states: ‘offer endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for biopsy of paratracheal and peri-bronchial intra-parenchymal lung lesions.’

17. Our consultant adviser says the reason for Mr B having the EBUS was to verify his existing lung cancer diagnosis and help with future treatment and pain relief. Therefore, we consider there was an appropriate basis for the Trust to offer Mr B the EBUS in accordance with the relevant NICE guidance.

18. We have identified an entry in Mr B’s hospital records timed at 6.33pm on 20 May 2022. The entry is from a junior doctor (Dr C) who was discussing the EBUS procedure with Mr B. It is documented that they ‘have to do the (EBUS) procedure’ and if Mr B does not have the procedure, ‘no one will touch him onwards.’ Our consultant adviser says that such procedures are not compulsory. They are recommendations based on the clinical situation. Therefore, we consider for Dr C to suggest that no one would touch Mr B if he did not have the procedure is incorrect and inappropriate language for a health professional to use. In our view, it paints a picture that Mr B was being pressurised into having the EBUS.

19. The GMC guidance on patients, partnership, and communication states: ‘You must recognise a patient’s right to choose whether to accept your advice, and respect their right to seek a second opinion.’ It also states: ‘You must treat patients fairly. You must not discriminate against them or allow your personal views to affect your relationship with them, or the treatment you provide or arrange.’

20. We consider this is a failing by the Trust contrary to the GMC guidance as Mr B was not obliged to have the EBUS, as Dr C suggested. Furthermore, it was incorrect and inappropriate for Dr C to suggest that Mr B’s future treatment could be affected if he did not have the EBUS. This causes some annoyance and frustration for Mrs A. We have made recommendations to the Trust about this.

21. However, at 9am on 23 May 2022, a staff nurse has documented in Mr B’s records that after a conversation with another doctor yesterday (Dr D), he now wanted the EBUS. From our consideration of this entry, it is noted that Mr B and his wife had discussed the importance of the EBUS, but Mr B wanted to be discharged as soon as it is completed.

22. As for whether Mr B was fit enough to have the EBUS on 24 May 2022, our consultant adviser says there is no specific guidance to assess whether a patient is fit to have an EBUS procedure but, based on Mr B’s hospital records at the time including normal observations on the morning of 24 May 2022, he was fit enough to tolerate the procedure.

23. We appreciate that Mr B had to travel to another site to have the EBUS, and Mrs A is concerned about the impact this may have had on him. Our consultant adviser says while this may have caused Mr B some minor inconvenience, he would have travelled to another site by ambulance with appropriate clinical support. It is noted that his observations were normal when he returned to the original site after the procedure, so there is no evidence that having to travel to have the EBUS had any negative clinical impact on Mr B’s condition.

Deterioration in condition

24. After Mr B’s EBUS procedure, he suffered a marked deterioration in his condition on 25 May 2022 and sadly died the next day. Mrs A says that nursing staff never identified her husband’s deterioration, and it took a phone call from her on 25 May 2022 before any action was taken, but it was too late.

25. Firstly, having considered Mr B’s hospital records, our nurse adviser says there is no indication of a deterioration in Mr B’s condition until Mrs A’s phone call on the afternoon of 25 May 2022. Mr B was then reviewed, and his observations taken at 4.58pm. We can see from the records that Mr B had been regularly reviewed throughout the day by different clinical staff. According to the records, no significant concerns or deterioration in his condition was raised until he became acutely unwell at approximately 4.40pm.

26. Our nurse adviser says that while Mr B was having his clinical observations taken at least 12 hourly since admission, this is in not in line with the NEWS guidance issued by NHS England and NICE. Since admission, Mr B’s NEWS score was predominantly 1 to 2 indicating that he was at low clinical risk. Nevertheless, the NHS England and NICE guidance indicates the minimum standard for frequency of monitoring for these scores is 4 to 6 hours.

27. There is evidence in the documentation that after speaking to Mrs A, the nurse assessed Mr B and immediately escalated his NEWS and condition to the Medical Emergency team within the Trust. This was in accordance with the RCP guidance.

28. Overall, our nurse adviser says the frequency of clinical observations can be adjusted by the medical team. Mr B had been on 12 hourly observations since admission with no concerns raised. Therefore, we consider the nursing care provided to Mr B up until his deterioration on the afternoon of 25 May 2022 was appropriate and in accordance with relevant guidance.

29. Given that Mr B had to be escalated on 25 May 2022 due to a deterioration in his condition, we have considered the subsequent care provided to him up until his sad death the following day.

30. Firstly, our consultant adviser says Mr B had stage 4 lung cancer. After a deterioration was noted in his condition on the afternoon of 25 May 2022, he was assessed for possible sepsis due to his high NEWS score. An urgent medical review was carried out and Mr B was placed on IV fluids and antibiotics to treat any infection. On the evening of 25 May 2022, Mr B had blood tests, an ECG, and a chest x-ray. Our consultant adviser says this was in accordance with the NICE guidance for suspected sepsis: recognition, diagnosis, and early management.

31. Furthermore, as the Trust suspected Mr B had a possible blood clot in his lung, our consultant adviser says it carried out a CT Pulmonary Angiogram. This investigation showed that while Mr B did not have a pulmonary embolism (PE), he did have pneumonia. Further treatment was provided for this and his sepsis.

32. Unfortunately, by approximately 10pm on 25 May 2022, our consultant adviser says it became apparent that Mr B was coming towards the end of his life. He was agitated overnight, and his breathing became less frequent, so morphine was provided to settle him as part of end-of-life care. Mr B deteriorated overnight and was found to be unresponsive by 6.25am on 26 May 2022. He sadly died at approximately 6.40am.

Mr B’s wishes

33. Mrs A says her husband knew he was terminally ill with cancer and therefore he did not want any treatment. He wanted to be discharged from hospital, but his wishes were never taken into consideration by the Trust in accordance with his care plan and a Do Not Attempt Resuscitation (DNAR) order that was in place.

34. Firstly, our consultant adviser says there is evidence in the records that Mr B had capacity to make his own decisions about his care. There is also evidence in the records that he wanted to go home, such as after the EBUS was completed. However, there is no evidence that he did not want treatment for his cancer. There are documented discussions in the records on 20, 21 and 25 May 2022 between Mr B, his family, and clinical staff about staying in hospital for treatment and the reasons for this, rather than being discharged to home. After explanations were provided, the records indicate that Mr B was content with this and understood the reasons why he needed to stay in hospital.

35. In summary, as we have said, Mr B had stage 4 lung cancer which he knew was terminal. Unfortunately, when Mr B was in hospital between 17 and 26 May 2022, he developed pneumonia and sepsis which caused his sad death.

1. We have seen a failing by the Trust regarding the terminology used by Dr C as documented in the records which indicates that Mr B was pressurised into having an EBUS procedure. We consider this causes Mrs A some annoyance and frustration about the care that her husband received from the Trust. We have not seen any other failings by the Trust regarding Mr B’s care.

2. Therefore, we will partly uphold Mrs A’s complaint about the Trust. These are our recommendations:

• the Trust should acknowledge that the terminology used by Dr C is incorrect and inappropriate language for a health professional to use, as summarised in paragraph 20, and apologise for the annoyance and frustration this causes Mrs A • the Trust should develop an action plan to address the failing summarised in paragraph 20. It should identify any specific reasons for these failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, as well as how these will be monitored.

36. In considering our recommendations, we have referred to the ‘NHS complaint standards.’ The Complaint Standards support organisations to provide a quicker, simpler, and more streamlined complaint handling service. They have a strong focus on:

• early resolution by empowered and well-trained people • all staff, particularly senior staff, regularly reviewing what learning can be taken from complaints • how all staff, particularly senior staff, should use this learning to improve services.

37. Therefore, in accordance with the NHS complaints standards, we recommend the following action by the Trust within the next six weeks:

• the Trust should acknowledge that the terminology used by Dr C is incorrect and inappropriate language for a health professional to use, as summarised in paragraph 20, and apologise for the annoyance and frustration this causes Mrs A • the Trust should develop an action plan to address the failing summarised in paragraph 20. It should identify any specific reasons for these failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, as well as how these will be monitored.

38. This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.