16. We have considered each of the issues Mr T has raised with us. Where issues are similar in nature, or closely related, we will address them collectively.
10 March discharge
17. Mr T says he raised concerns his mother’s feet were still swollen (oedema), and she had ‘shakes’ (tremors) at the point of discharge on 10 March.
18. He adds that his mother was taken from the ward to his car in a wheelchair and was unable to get into his car unaided. Mr T says his mother was not medically fit for discharge on 10 March.
19. Oedema is a build-up of fluid. Tremors are characterised by uncontrolled movements in parts of the body.
20. The Trust says Ms B appeared well following review on 10 March. It says she had mobilised to the toilet without assistance and her ankle oedema was not serious enough for her to remain in hospital.
21. It adds her tremors were long standing and likely to be ‘essential tremor’. This is one of the most common types of tremors and can affect the hands, arms, lower limbs, head and voice. It is not typically considered a dangerous condition but can worsen during times of illness.
22. The Trust says Ms B was well enough to be discharged and it arranged a ‘three times a day package of care’ to support her at home.
23. ‘Annexe D’ of DOHSC discharge guidance sets out the criteria for someone to remain in hospital.
24. It says where a patient requires intensive care unit or high-dependency unit input, requires oxygen therapy, intravenous (IV) fluids, has undergone recent lower limb or abdominal surgery or has a NEWS2 score greater than three (NEWS2 is an early warning scoring system to assess acute illness), they should be considered for a further stay in hospital.
25. It says the patient must be discharged if each criterion does not apply.
26. Our physician adviser says Ms B did not meet any of the criteria to remain in hospital on 10 March.
27. She had a NEWS2 score of two and was not on IV medication or oxygen. In terms of her functional impairment, we can see a physiotherapist documented Ms B was independently mobile with a frame and, as set out above, a package of care for home-based rehabilitation had been arranged.
28. We recognise Mr T is very concerned and frustrated about the Trust’s handling of his mother’s discharge on 10 March. We appreciate he very strongly feels his mother’s lack of mobility and overall condition should have meant she remained in hospital. We also acknowledge these events were likely very upsetting for both him and his mother.
29. Having carefully considered the available evidence, we are satisfied the Trust discharged Ms B in line with DOHSC discharge guidance.
30. As set out above, Ms B did not meet the criteria set out in DOHSC discharge guidance to remain in hospital. The Trust also appears to have acknowledged she had some functional impairment and planned for home-based rehabilitation to assist with this.
COVID-19 testing 31. Mr T is concerned his mother was not tested for COVID-19 upon discharge on 10 March. He says she tested negative at the beginning of her initial admission (1 March) but tested positive following readmission on 13 March. Mr T says his mother likely caught COVID-19 while she was in hospital.
32. Mr T says staff could have discovered her infection sooner if they had tested on 10 March and this may have led to earlier treatment.
33. Mr T adds there were new cases of COVID-19 on his mother’s ward before her discharge on 10 March. He says this supports his view that she should have been tested for the virus before being discharged.
34. The Trust says it tested Ms B for COVID-19 on 2 and 5 of March, which came back negative. It says Ms B did not display any symptoms which required further testing prior to her discharge on 10 March.
35. There is no guidance which says patients should be routinely tested for COVID-19 at discharge from hospital. We will refer to GMC good practice guidance here which sets out how doctors can provide good care.
36. Section 15 of GMC good practice guidance says doctors must adequately assess a patient’s conditions and promptly provide or arrange suitable advice, investigations or treatment where necessary.
37. As set out a above, our physician adviser says there is no guidance which says patients should be routinely tested for COVID-19 at discharge. They agree Ms B did not display any symptoms or signs of COVID-19 infection prior to her discharge to warrant further tests.
38. We do not see indication of a failing in the Trust not carrying out a COVID-19 test at discharge on 10 March.
39. This is because Ms B did not exhibit signs of infection up to or at the point of discharge, so there was no clinical indication for further COVID-19 testing. We see the Trust broadly acted in line with GMC good practice guidance.
Antibiotics 40. Mr T says his mother’s condition was improving every day until 23 March and she could have got better if antibiotic treatment had continued. He is concerned the Trust stopped treatment as it felt his mother was unlikely to survive.
41. The Trust says Ms B continued to be treated up until her death on 24 March. It says it did not withhold any treatment.
42. NICE pneumonia guidance recommends meropenem (an antibiotic) when treating hospital acquired pneumonia. It recommends a five-day course followed by review.
43. GMC good practice guidance, set out at paragraph 36, is also relevant here.
44. We can see Ms B had an eight-day course of meropenem which ended on 23 March. Our physician adviser says there is no evidence extending antibiotic treatment beyond seven days is clinically effective.
45. As such, our physician adviser says the eight-day course Ms B received was appropriate to treat her pneumonia. We can also see the doctor’s decision to stop meropenem was discussed and agreed with the Trust’s infection specialists.
46. The reason for doctor’s decision to stop meropenem on 23 March was because the course had come to an end. We are therefore satisfied the Trust’s use of meropenem is in line with both NICE pneumonia guidance and GMC good practice guidance.
Oxygen levels
47. Mr T says he noticed his mother was coughing a lot when he visited her on 23 March and likely needed more oxygen. He says he raised concerns with a nurse but is worried her oxygen levels were not managed correctly at this critical stage in her care.
48. The Trust says it correctly managed Ms B’s oxygen levels. It says she was on 6 litres of oxygen initially and this was increased to 10 litres alongside nebuliser treatment following review late night on 23 March.
49. Nebuliser treatment works by converting medicine into a fine mist which can be easily absorbed by the patient through breathing. It helps to open the airways and reduce inflammation.
50. BTS guidance recommends oxygen therapy should be titrated (adjusted) to achieve target oxygen saturations of 88-92% for patients with hypercapnia (high blood carbon dioxide).
51. Ms B’s observations show most of her oxygen saturations were within this target range. When her oxygen saturation levels dropped, the Trust’s nursing staff increased her oxygen levels accordingly.
52. On the morning of Ms B’s death her oxygen saturation was 88% at 06.45am. Our physician adviser says she was on 11 litres of oxygen at this stage, which is near the maximum it is possible to give. Despite this treatment, Ms B sadly died a few hours later.
53. Having carefully considered the available evidence, we are satisfied the Trust managed Ms B’s oxygen in line with BTS guidance.
54. We hope our statement is able to provide Mr T with some reassurance as we appreciate he is very concerned about his mother’s oxygen levels in the last days of her life.
Palliative/end-of-life care and NG tube feeding
55. Mr T says a doctor called him on 14 March to say they would be putting his mother on palliative care. A few days later, on 17 March, Mr T says a doctor wanted to place his mother on end-of-life care, which involved stopped her antibiotics and any food and fluids she was receiving.
56. Palliative care focusses upon providing relief from symptoms to improve quality of life for people who have serious, life limiting illnesses. End-of-life care is a specific type of palliative care which applies when a patient is nearing the end of their life. The primary goal is to ensure comfort and dignity in the time the person has left.
57. As set out in the previous section of this statement, the Trust says it did not withhold any treatment and continued to treat Ms B up to her death on 24 March.
58. Section 1.3.2 of NICE nutrition guidance says nutritional support should be considered in patients who have eaten little or nothing for five days. Section 1.7.1 recommends consideration of enteral (NG tube) feeding if oral intake is unsafe.
59. GMC good practice guidance, set out at paragraph 36, is also relevant here.
60. While we can see palliative care was discussed, both between clinicians and with Mr T (which we will discuss in more detail later in this statement), there is no evidence to indicate it was put in place. We have also seen no evidence in the records to indicate end-of-life care was discussed or considered.
61. As we have already set out, Ms B received antibiotics up until 23 March and they were stopped because the course had come to an end. This decision was not because of any palliative decision making. Alongside this, oxygen continued to be managed and given in increased quantity when needed up until Ms B’s death.
62. In terms of food and fluids, we can see no indication of a delay in providing Ms B with NG tube feeding when it was indicated.
63. A dietician reviewed Ms B on 20 March and recorded she had not eaten for five days. A speech and language therapist also reviewed her on 20 March and noted her swallow was unsafe. Following discussion with the Trust’s doctors an NG tube was inserted, and NG tube feeding started on 21 March.
64. We are satisfied there is no evidence the Trust put in place either palliative or end of life care. Further to this, we see no indication the Trust withheld NG tube feeding. Overall, the Trust appears to have managed Ms B’s condition in line with both NICE nutrition guidance and GMC good practice guidance.
Communication
65. We understand Mr T is concerned staff did not update him regularly enough throughout his mother’s two admissions.
66. Our principles say public bodies should communicate effectively, using clear language people can understand which is appropriate to them and their circumstances.
67. In looking through the records, we can see updates were provided to family members throughout the first and second admission periods.
68. For example, we can see evidence staff updated, or attempted to update family members on around five occasions during the initial admission period between 1 and 10 March. We can see similar contact was made or was attempted during the second admission period between 13 and 24 March.
69. We appreciate this was an incredibly difficult time for both Mr T and his family and they wanted to know how Ms B was and felt the Trust did not provide information regularly enough.
70. Having carefully considered this, we think the Trust made reasonable attempts to update family where it could. Overall, we consider such contact to be in line with our Principles.
71. We acknowledge Mr T spoke with a physiotherapist on 8 March and asked for a doctor to call him back as he was unhappy with plans to discharge his mother, but did not receive one. Following this, we can see a nurse called Mr T on 10 March to discuss this.
72. While we appreciate Mr T asked for doctor to call him back and was frustrated he did not receive one, we can see a nurse called him back to further discuss discharge planning and answer any questions he had. The Nurse noted that following this discussion, Mr T was happy with the discharge plan.
73. Having carefully considered this part of the complaint, we do not see this shortcoming is so far outside of our Principles to be considered a failing. We have therefore decided to take no further action on it.
74. Mr T also tells us he was placed under ‘substantial unnecessary stress’ when a doctor asked for his agreement to place his mother on end-of-life care.
75. Section 40 and 44 of GMC decision making guidance says doctors must weigh up the benefits of treatment to prolong a patient’s condition or manage their symptoms against the burdens and risks for that patient. It says any decision to stop active treatment should be shared with the patient’s family.
76. Section 33 of GMC good practice guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information.
77. On 15 March, a doctor discussed with Mr T that if his mother deteriorated further, despite active treatment, they may consider switching her to a palliative care pathway.
78. We have found no evidence to suggest doctors asked Mr T for permission to place his mother on palliative care. Instead, we can see doctors correctly discussed the possibility of palliative care with family members to manage their expectation as she may not recover.
79. The decision to place a patient on palliative care is a medical decision and does not require agreement from family. While no decision was made to place Ms B on palliative care, the Trust’s doctors did discuss the potential for this, if she continued to deteriorate. This approach is in line with both GMC decision making guidance and GMC good practice guidance.
Summary
80. Having carefully considered the available evidence, we have seen no indication something went wrong with the care Ms B received and have therefore decided to take no further action in Mr T’s complaint.
81. We know our primary investigation cannot change what happened or take away Mr T’s, or his family’s pain. We sincerely hope our decision statement addresses the concerns Mr T has about what happened and provides some reassurance around the care his mother received.