17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
18. Mr B told us he recognises his father’s cardiac arrest was unexpected. However, he says if the Trust had not transferred him to ward F6 the day after surgery, the arrest could have been noticed and treated quicker in intensive care.
19. The records show Mr A underwent the CABG procedure at 12.30pm on 29 June 2023. The Trust transferred him to intensive care at 5.35pm. Around 1.30pm on 30 June, the Trust then transferred him from intensive care to ward F6. Mr A’s cardiac arrest is recorded as being at 3.51pm.
20. Mr B told us the Trust had told his father he would be in intensive care for two nights following his surgery, but he was only there for one. In its complaint response, the Trust apologised for the confusion as it was standard practice to admit a patient such as Mr A to intensive care for a minimum of 12 hours (one night) following surgery.
21. We sought a advice from our adviser who referred to the GIRFT report. They explained how there are different local arrangements at different cardiac surgery centres for how long somebody would spend in intensive care after cardiac surgery. The report suggests productivity could be improved with shorter stays in intensive care post-operatively and it is accepted practice for some units to keep a patient in intensive care for only one night if they are well enough to be transferred the next day.
22. The FICM provision guidelines refers to the different levels of inpatient care for adults. Level 0 is ward care, Level 1 is enhanced care, Level 2 is critical care (formerly known as high dependency) and Level 3 is intensive care. The guidelines detail the kind of care a patient at each level might require.
23. It describes level 1 care as being for patients:
• requiring more detailed observations or interventions, including basic support for a single organ system and those ‘stepping down’ from higher levels of care.
• requiring interventions to prevent further deterioration or rehabilitation needs which cannot be met on a normal ward.
• who require ongoing interventions (other than routine follow-up) from critical care outreach teams to intervene in deterioration or to support escalation of care.
• needing a greater degree of observation and monitoring that cannot be safely provided on a ward, judged on the basis of clinical circumstances and ward resources.
24. Our adviser explained Mr A was initially being cared for in intensive care (level 3) following his surgery. Before the Trust transferred Mr A to ward F6, the records outline his condition in a consultant note. It states Mr A still had a central line (cannula into a large central vein) and pacemaker box in place. In addition, he required additional monitoring with telemetry/holter monitoring. A holter monitor is a portable electrocardiogram (ECG) device which records the hearts activity.
25. In addition, Mr A was no longer receiving noradrenaline (to maintain blood pressure) and had satisfactory observations. Our adviser told us Mr A’s condition at this time describes somebody who could be safely managed with level 1 (enhanced) care, but not level 0 (standard ward based) care, as per the FICM provision guidelines.
26. The FICM enhanced care guidance describes enhanced care (level 1) and what this would look like in terms of aspects such as staffing ratios and skills of staff. For level 1 enhanced care, it says ‘The nurse:patient ratio should match patient acuity, skill mix, volume of work and the variety of services offered’.
27. We requested further information from the Trust regarding the level of care which was available to Mr A on ward F6 on 30 June 2023. It told us that on the day of Mr A’s cardiac arrest, there was a mixture of band 5,6 and 7 nurses on duty with a nurse:patient ratio of 1:5. The nurses were trained in ECG recognition, caring for patients with pacing wires, and nursing care for post operative cardiac surgery amongst other things.
28. Our adviser reviewed all the information provided by the Trust on the level of care provided on ward F6. They confirmed the additional information described an appropriate skill mix of staff on the ward and an appropriate nurse:patient ratio given the ward provides a mixture of both level 0 and level 1 care.
29. We consider the Trust acted in line with the FICM provision guidelines, enhanced care guidance and the GIRFT report when it transferred Mr A from intensive care to ward F6 on 30 June 2023. The advice we have received told us this was a medically appropriate decision, and we are satisfied the ward he was transferred to provided an appropriate level of care for his needs at the time. Despite receiving an appropriate level of care, Mr A sadly suffered a rare complication on day one post surgery.
30. Although it is apparent that ward F6 provided appropriate level 1 care for Mr A, our adviser said best practice would be for the Trust to have a standard operating procedure (SOP) or document that describes specifically what care is required for level 1 on that ward. This would include the requirements these patients have, to receive level 1 care in a mixed ward environment.
31. This is also suggested in the FICM enhanced care guidance, ‘It will be advantageous to involve Critical Care in establishing a clear policy on the level of monitoring and treatment that it is appropriate to be provided by the Enhanced Care service. This will vary depending on local need, but the use of SOPs will ensure patient safety.’
32. To clarify, we have not seen indications of a failing in the care the Trust provided. We have included this information in our statement for transparency with the family. We will also share it with the Trust. This is to give the Trust the opportunity for future consideration on improvements.
33. We recognise Mr A, Mr B and his whole family have experienced an immensely distressing time over the last 18 months. We are very sorry the outcomes for Mr A are not more positive. We hope our explanations set out above are clear and helpful in understanding the decisions taken by the Trust and we wish the family the very best for the future.