13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link some of the events complained about with the negative impact Mrs A has claimed. Furthermore, we have found the Trust has already done enough to put right the impact of other events.
DNAR and nurse’s comment
14. Mrs A says a DNAR order was placed on Mr B without appropriate next of kin and family input. Mrs A also says a staff nurse passed comment on the timing of Mr B’s DNAR which was inappropriate.
15. When Mr B came into hospital on 18 November 2022, the records indicate that he had slight confusion and agitation, but he was conversant. He had some kidney impairment due to dehydration and acidity in his blood. He also had a low body temperature, also called hypothermia. Our adviser says this suggested a possible infection and the Trust thought Mr B was suffering from viral encephalitis although this was not certain.
16. Given this, our adviser says Mr B was treated appropriately with antibiotics and fluids. He also had a CT brain scan and a chest x-ray, but these did not show anything conclusive. Up until the afternoon of 22 November 2022, Mr B’s condition was relatively stable. However, at this point, Mr B suffered a spike in his temperature and his oxygen levels and blood pressure both dropped.
17. Therefore, our adviser says Mr B was given a DNAR on 22 November 2022 because the Trust had assessed him and conducted appropriate investigations. Despite this, Mr B’s condition had not improved, and his level of consciousness had dropped. Given this, our adviser says that DNAR was appropriate for him at that time, as the deterioration in spite of treatment implies a poor prognosis with cardiopulmonary resuscitation futile and prolonging suffering.
18. The GMC guidance on treatment and care towards the end-of-life states:
‘If a patient lacks capacity, you must consult with any legal proxy and others close to the patient about the DNAR decision and the reasons for it unless it is not practicable or appropriate to do so. These discussions should take place at the earliest practicable opportunity and should include a sensitive and careful explanation that the intention is to spare the patient treatment that will be of no benefit, not to withhold any other care or treatment the patient will need.’
19. Our adviser says the records indicate that the Trust spoke to Mr B’s brother, in accordance with GMC guidance, as he was documented as his next of kin in his medical records. Unfortunately, by this point (22 November 2022) Mr B was not capable of making his own decisions about care. Our adviser has added that while the Trust could have attempted to contact other family members at this point such as Mr B’s wife, there was no requirement for them to do this as the designated next of kin had already been spoken to. It should also be noted that ultimately, DNAR is a medical decision for clinicians to make in the best interests of the patient which is what happened here.
20. Overall, we have not seen any indications of maladministration or service failure by the Trust regarding this point.
21. As for a nurse stating that she would have placed a DNAR order on Mr B earlier than the consultant did, the Trust said the nurses involved do not recall this conversation with Mrs A, so they were unable to investigate it any further. We appreciate that Mrs A would have been distressed by such a comment, but we were not party to this incident, so we cannot verify what was said.
22. In any case, the Trust apologised for this situation and acknowledged that it would have been an inappropriate comment for a nurse to make. The Trust suggested that nurses may have been distracted at shift changeover whilst also having a conversation with Mrs A.
23. As a result, internal discussions have taken place to remind appropriate staff not to engage in any form of unacceptable behaviour when communicating with patients and their families. This was documented in the Trust’s complaint response, and we consider it is appropriate remedial action in the circumstances. As such, there is no further action for us to take regarding this point.
Hydration status and sponge
24. Mrs A says Mr B’s intravenous fluid (IV) bag was left empty even when his family asked for it to be changed, and as a result he was left dehydrated at the end of his life. Mrs A also says her family were refused a sponge to dampen Mr B’s lips that were dry and were told not to dampen his lips due to his DNAR status. We appreciate this would have been alarming for Mrs A and her family.
25. The Trust has said in its complaint response that IV fluids were prescribed and signed for as administered when Mr B was in hospital. Therefore, we have asked our adviser if the records provided by the Trust covering 18 to 23 November 2022 reflect what the Trust has said.
26. Our adviser says that Mr B’s fluid charts from 18 to 23 November 2022 document that small amounts of fluid were being taken, but not all the time. His medication charts show that Mr B was given bags of fluid on 19, 20 and 21 November 2022. The records show that Mr B’s sodium level was increasing between 19 and 21 November 2022, but his urea and creatinine levels (markers of kidney function) were decreasing, indicating kidney function improving. Our adviser says this implies that Mr B’s dehydration was being addressed by the fluids he was taking.
27. Even if Mr B’s IV bag was left empty for lengthy periods, our adviser says that even though Mr B was in hospital unwell and had some dehydration with related infection, he did not require continuous fluids. He needed some fluids which were provided, but not on a continuous basis. Ideally, Mr B would have taken more fluids when he was in hospital, but our adviser says there is no evidence in the records that dehydration contributed to his death. Unfortunately, he developed sepsis when he was in hospital, and this led to his sad death on 23 November 2022.
28. Overall, we have not seen any indications of maladministration or service failure by the Trust regarding this point.
29. We appreciate that Mr B’s family requested a sponge to dampen his dry lips and make him feel more comfortable, and then a tissue as there were no sponges available. Mrs A says the family were then told they could not give Mr B any fluids due to his DNAR status. This was concerning for them as Mr B was suffering with some dehydration.
30. The Trust confirmed that sponges are no longer used in hospital. It acknowledges that not all equipment and supplies had been placed into the supply cupboard on Mr B’s ward, but staff should have been able to access these from other wards if required. As a result, the Trust has taken remedial action to ensure all staff continue to source consumables for patient care from neighbouring wards.
31. The Trust said it was unable to clarify why a nurse may have advised Mr B against having any water due to his DNAR status, as any such decision would not have any effect on his ability to eat or drink. It may have been said as Mr B was nil by mouth at the time although if it was, this evidences a miscommunication for which the Trust has apologised.
32. As the Trust has apologised and taken some appropriate remedial action, we consider there is no further action for us to take regarding this point.
Complaint response
33. Mrs A is concerned about how long it took for the Trust to respond to her complaint about Mr B’s care.
34. We can see from the records that Mrs A made a complaint to the Trust on 26 March 2023 which it received the following day. The Trust required consent from the legal next of kin, so it requested this on 29 March 2023 but, unfortunately, there were some delays in the Trust receiving consent. It was not received until 9 May 2023.
35. Over the next few months, the Trust had to request input from different staff and departments during its investigation of the complaint. As a result, there were delays and deadlines had to be amended. This meant that Mrs A did not receive a response to her complaint until 15 December 2023 approximately 7 months after next of kin consent had been received. We recognise that this delay must have been frustrating for Mrs A as she sought answers about her brother’s care.
36. Paragraph 14(3) of the NHS Complaints Regulation states: ‘In paragraph 4, “relevant period” means the period of 6 months commencing on the day the complaint was received, or such longer period as may be agreed before the expiry of that period by the complainant and the responsible body’.
37. This indicates the Trust did not provide a response to Mrs A’s complaint within the timeframe stipulated under the NHS Complaints Regulations, once next of kin consent had been received. We note that the Trust apologised for the delay in its complaint response which it said was due to operational reasons.
38. We have approached the Trust about this, and it has acknowledged that the length of time taken for Mrs A’s response was much longer than it would have anticipated. In addition to this, a scoping exercise began in August 2023 and in December 2023 the Trust introduced a new complaints process. Cases have a 35-working day deadline and while this target is not always met, the Trust has provided assurances that it has dramatically reduced the timescales involved in responding to complaints. It also allocates an investigation officer who discusses the concerns with the complainant and communicates with them throughout this process.
39. As the Trust has apologised for the delay and taken appropriate remedial action to reduce delays in dealing with complaints, We consider there is no further action for us to take regarding this point.
40. In summary, we consider that a DNAR was appropriate for Mr B due to his clinical circumstances and the process followed was what we would expect to see in accordance with relevant guidance. Even though the records indicate that Mr B’s fluid management was not ideal, we consider he was adequately hydrated when he was in hospital. The Trust has apologised for the nurse’s comment about DNAR and for the issues around the request for a sponge, as well as taking appropriate remedial action. Similarly, while it is clear there were delays in responding to Mrs A’s complaint contrary to the relevant legislation, the Trust has apologised and taken appropriate remedial action.
41. We appreciate that seeing Mr B suffering at the end of his life was difficult to witness for Mrs A and her family. Furthermore, the feeling that this was at least in part exacerbated by some inadequate and insensitive care must have made it a worse experience for all of them. Unfortunately, Mr B suffered a marked deterioration in his condition whilst he was in hospital on 22 November 2022 despite receiving appropriate treatment. He sadly died the following day after developing sepsis. While there are indications that the Trust did not get everything right as regards its management of Mr B, there is no indication this had any significant negative impact on this care. Overall, we consider the remedial action already taken by the Trust means there is no further action for us to take.