17. Under the law, we have the discretion to decide we have resolved a complaint without conducting a detailed investigation. This includes if we can deliver the outcomes a complainant asks us to achieve at an earlier point in our case handling process.
Nursing care
18. Miss O describes a number of occasions where she feels the nursing care fell below what she expected for Mrs R.
19. Miss O says Mrs R was not given a wristband immediately. She says the Trust conducted blood tests and ultrasounds over a number of days despite this. Miss O says on either 22 or 23 May 2023 a clinician refused to take blood because Mrs R did not have a wrist band.
20. We can see from the Trust’s response dated 7 September 2023, it has accepted Mrs R did not receive a wristband immediately and apologised for this. The Trust explained staff are required to check a patient’s identity prior to carrying out treatment or procedures to ensure patient’s safety and to avoid errors happening.
21. The Trust went on to say it has now introduced a team briefing session which happens at 11am every day. This briefing session requires attendance from the ward teams so they can discuss care plans for patients as well as request support and incorporate all patient safety concerns.
22. We have carefully considered this element of the complaint. We are sorry to hear about the impact this has had on Miss O.
23. The NHS Complaint Standards says wherever possible staff explain why things went wrong and identify suitable ways to put things right for people. It says staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
24. We have considered the impact of this issue, taking into account what Miss O told us.
25. Miss O was worried during the time Mrs R did not have a wristband. Miss O says she cannot be sure the blood tests and ultrasounds are Mrs R’s results because of the lack of wrist band.
26. Our guidance on financial remedy says for injustices such as annoyance, frustration, worry or inconvenience arising from a single incidence of maladministration where the effect on the individual is of short duration, we consider an apology to be an appropriate remedy.
27. Having carefully considered this, we consider the apology to have resolved this part of the complaint. The Trust has apologised to Miss O and explained what actions they are taking to prevent this happening again. This resolves this part of Miss O’s complaint to us and we have decided not to consider it further.
28. On 23 May 2023 Miss O says whilst she was visiting Mrs R, a nurse came in to say her cannula had to be changed because it was positioned incorrectly and there was a build up of fluid. Miss O goes on to say that the clinicians said Mrs R had to be given reversal medication because there was too much fluid.
29. She says Mrs R had been complaining about pain around the cannula since it had been put in on 18 May 2023. Miss O is also worried that the incorrect position of the cannula caused the fluid overload.
30. We asked the nursing adviser about the cannula. they explained the high impact interventions publication says the need for a cannula and health of the cannula site should be documented at least once a shift. This publication also says the area around the cannula should be visually inspected at a minimum during each shift. When the cannulas are peripheral vascular catheters (cannulas in the arm), a visual infusion phlebitis score (a tool used to assess the early signs of inflammation of a vein) should be recorded.
31. We reviewed Mrs R’s hospital records and could only find two references to the cannula. The first was on 22 May 2023 by a doctor who noticed the IV fluids were at the same level as eight hours ago. Mrs R had a new cannula fitted and the Trust increased fluids to six hourly.
32. The second entry is on a nursing evaluations on 22 May 2023 where the visual infusion phlebitis score was zero. A score of zero means the insertion site of the cannula appears healthy and there are no signs of inflammation.
33. Our nursing adviser was critical of the documentation and identified that it was not possible to say whether the cannula was sited correctly at any specific point.
34. We have looked at all of the nursing records for Mrs R. We can see there are missing nursing checks for her. This is despite there being logs of medications provided by a nurse at certain times.
35. The NMC Code says nurses must complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event.
36. The lack of records and the cannula issues are indicative of a failing. We have spoken to the Trust about this. It says it accepts the records are not as detailed as they would have liked.
37. Miss O says she was worried about Mrs R as she had been complaining about pain at the cannula site between admission on 18 May 2023 and the time the cannula was repositioned on 22 May 2023.
38. We have been unable to give an answer to Miss O about the cannula for the whole of this period because of the lack of records. This has caused Miss O frustration and distress for a number of months.
39. The NHS Complaint Standards says staff are to explain why things went wrong and identify suitable ways to put things right for people. If it is not possible to put the person back into the position they were the remedy should compensate them appropriately.
40. Our guidance on financial remedy says distress, worry, annoyance and similar injustice of the sort which a healthy adult would be expected to deal with on a regular basis, without external support, and which does not impact on the affected person’s day to day functioning, we consider an apology is not enough and a financial remedy of up to £550 is appropriate.
41. We have spoken with the Trust about this aspect of the complaint. The Trust say they will write to Miss O to apologise and pay £500 in recognition of the impact on Miss Horsham and her family. This outcome relates to the impact of poor record keeping here. It also relates to the impact of a further issue with poor record keeping we consider later in this statement.
42. Having carefully considered this, we consider these actions to be in line with the NHS Complaint Standards. This is because Miss O is provided with an apology and a financial remedy. This resolves this aspect of the complaint to us and we have decided not to consider it further.
43. To seek some reassurance for Miss O, we also asked the oncology adviser about the cannula and fluid overland. Our oncology adviser explained if a cannula does come out or it is not sited properly, the IV fluid goes into the subcutaneous (under the skin) area of the body. This would not cause fluid overload.
44. Miss O told us there was the incident with the nurse who came to put her mum on the commode. It did not have a pan on it, however Mrs R was mobile at this point and wanted to go to the toilet. It was degrading that the nurse kept forcing her mum onto the commode. It got to the point where Miss O and her brother unplugged her and helped her get to the toilet so she could use it and freshen up.
45. We can see from the Trust response dated 7 September 2023, it has apologised to Miss O for this and explained a sister will reiterate to staff they should all take into account patients’ wishes and that patients are listened to.
46. We have carefully considered this part of the complaint. We are sorry to hear about the impact this has had on Miss O.
47. Miss O explains it was distressing at the time to see her mum’s wishes to be disregarded and to have to intervene.
48. The NHS Complaint Standards says wherever possible staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
49. Our guidance on financial remedy says for injustices such as annoyance, frustration, worry or inconvenience arising from a single incidence of maladministration where the effect on the individual is of short duration, we consider an apology to be an appropriate remedy.
50. Having carefully considered this, we consider the apology and actions have put things right. The Trust have apologised to Miss O and explained what actions it is taking to prevent this happening again. We have decided not to consider this further.
Failure to treat
51. Miss O says it felt it was impossible to get care and treatment. She says that nobody was checking on her mum and they did not seem to be doing anything.
52. Miss O says that the only time she spoke with a doctor was on the Friday 19 May 2023 and a nurse said there was nothing to worry about. Miss O goes on to say when the doctors attended on 22 and 23 May 2023, there was a junior doctor but they did not do anything for Mrs R when she was in so much pain. Miss O describes the doctor just shrugging when she asked him to do something.
53. Miss O says this was very distressing as the junior doctor went on to say they could not do anything until a more senior doctor came on to shift the next day. Miss O says she had to scream for help and refused to leave until something was done.
54. She says the Trust performed an ECG on the evening of 22 May 2023 to see if Mrs R was having a heart attack. Following the tests the doctor said she was not having a heart attack so it was probably indigestion. She was still in a lot of pain and very distressed being unable to lie down and hardly speak. The doctor said at this point he could give a bit of oramorph (a liquid form of morphine, a drug which is often used for pain relief). This helped her lie down.
55. When Mrs R was taken to the intensive care unit (ICU) on 24 May 2023 a nurse asked what medication Mrs R had taken, and Miss O explained oramorph, indigestion tablets, diarrhoea tablets and half a zopiclone (a sleeping tablet). The nurse said there would be no way Mrs R would have been given the oramorph and diarrhoea tablets because of her condition. Miss O says later on the nurse denied saying this and retracted what she was saying.
56. She feels Mrs R should have been moved to intensive care sooner and it feels like that if she had not demanded help then her mum would have died in the ward she was on.
57. We asked our oncology adviser about the treatment Mrs R received at the Trust. They explained Mrs R was admitted to an oncology ward at the Trust with an acute kidney injury due to chemotherapy and likely sepsis. Mrs R’s kidneys were not working properly. She suffered from diarrhoea. This means she was losing fluids. Mrs R’s infection levels were high so the Trust gave her antibiotics. Mrs R was on IV fluids, and sodium bicarbonate (this can help keep kidney disease from getting worse). Daily bloods were taken to monitor levels and renal input was sought twice.
58. NICE guidance NG148 says consider referring a patient to a nephrology (renal) specialist with severe illness might benefit from treatment but there is uncertainty as to whether they are nearing the end of life. Our adviser explained the treatment as described above is in line with this guidance.
59. Mrs R unfortunately suffered from an acute event on the evening of 23 May 2023. Mrs R started having desaturations (drops in blood oxygen levels), difficulty breathing, increased heart rate and pain in her back. The Trust sought advice from the critical care team at 12.43am on 24 May 2023 and she was admitted to critical care on 24 May 2023 at 1.36am.
60. Our adviser explained the FICM guidelines say • The decision to admit to the critical care unit and the management plan must be discussed with the duty consultant in Intensive Care Medicine.
• There must be documentation in the patient record of the time and decision to admit to critical care • Patients must be reviewed, in person, by a consultant in Intensive Care Medicine as urgently as the clinical state dictates and always within 12 hours of admission to critical care
61. We can see from the records Mrs R was assessed in the evening of 23 May 2023 on a regular basis and was reviewed by an intensive care consultant at 12.36am on 24 May 2023. Mrs R was admitted to intensive care at 1.36am on 24 May 2023. This seems to have been in line with the requirements of the FICM guidelines we set out above. Based on this, we have not seen an indication of a failing here.
62. We can see from the hospital records there are no entries relating to the evening of 22 May 2023 and the early morning of 23 May 2023.
63. GMC Good medical Practice 2013 says clinicians should formally record work and it must be clear, accurate and legible. It says clinicians should make records at the same time as events they are recording or as soon as possible afterwards.
64. The lack of documentation for the evening of 22 May 2023 shows an indication of a failing. The Trust has not recorded the reported symptoms of Mrs R, the reasoning for the ECG performed or the reason for providing oramorph.
65. This has meant we are unable to provide an explanation to Miss O. This has lead to frustration and upset.
66. We have carefully considered the claimed failing Miss O has brought to us in her complaint about the Trust. We are sorry to hear about the impact the evening of 22 May 2023 has had on Miss O and her brother.
67. We have discussed the lack of records with the Trust. It has accepted the record keeping is insufficient and will write to Miss O to apologise and offer £500 in recognition for the impact this has had on her. This is to recognise and put right the impact of this problem with record keeping, and the issue with record keeping we covered earlier in this statement. So the Trust will provide £500 in total covering both issues.
68. Having carefully considered this, we consider these actions have resolved the complaint from Miss O. We are mindful a prolonged investigation into what happened into the events of 22 May 2023 is not going to result in any different outcome for Miss O and her family.
69. This now resolves this part of Miss O’s complaint to us and we have decided not to consider it further.
Conclusion
70. We realise how difficult this matter has been for Miss O and we thank her for bringing her complaint to us. We hope the Trust’s further apology, explanation and financial remedy will bring some closure. We hope she takes some reassurance from knowing the Trust has taken steps to change procedures and that the complaint was worthwhile.