16. 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.
Admission 1 - 19-24 October COVID-19 treatment 17. Mr B complains that staff did not provide his father treatment for COVID-19, which he contracted during his admission.
18. The Trust say that Mr B snr did not require respiratory support.
19. Mr B snr had COPD [chronic obstructive pulmonary disease] and was on home ambulatory oxygen (oxygen used on walking, not at rest). We will go on to discuss the use and Mr B snr’s need of the ambulatory oxygen in more detail in the next section, starting at paragraph REF _Ref185241244 \r \h \* MERGEFORMAT 27.
20. The COVID-19 guidance says that ‘management predominantly depends on disease severity and focusses on the following principles: isolation at a suitable location, infection prevention and control measures, symptom management, prevention of disease progression, optimised supportive care, and organ support in severe or critical illness.’ The guidance goes on to provide a description of the clinical classifications of COVID-19. It describes patients who have a critical illness as those who have ‘respiratory failure, septic shock, and/or multiple organ dysfunction’. The COVID – 19 Guidance says that clinicians should, ‘start supportive care according to the clinical presentation’.
21. In addition to the above guidance specifically written for the treatment of patients with Covid-19, paragraph 16.b of the GMC Good Medical Practice guidance says that doctors must, ‘provide effective treatments based on the best available evidence’.
22. The records show that Mr B snr’s normal oxygen saturations at home were 86% on air. This means without the use of additional oxygen. His saturations upon admission are recorded as 89% on air, so normal for him.
23. On 24 October, after his diagnosis of COVID-19, his oxygen saturations remained normal, for him, at 87%. Our physician adviser confirms that Mr B snr did not require additional oxygen beyond his normal oxygen for use when walking.
24. As per his oxygen saturation levels, Mr B snr did not have severe or critical COVID-19 disease as his oxygen saturation levels remained within his normal range, therefore he did not qualify for any specific COVID-19 therapy such as ventilation or organ support listed in the COVID-19 guidance. Mr B snr was moved to a side room for appropriate isolation and was treated with infection control measures and symptom management for a mild strain of COVID-19.
25. After careful consideration of all the evidence and our physician advisers comments, we have seen no indication staff did not act in line with the COVID-19 guidance and the GMC guidance.
26. We understand it must have been distressing for Mr B knowing that his father had developed COVID-19 during his admission. We hope we have been able to provide some reassurance that his father was cared for in line with relevant guidance.
Discharge arrangements 27. Mr B complains that staff did not follow the appropriate discharge process when discharging his father and 'assumed' he had home oxygen already available.
28. The Trust say that Mr B snr was discharged because he did not need respiratory support.
29. The hospital discharge guidance says that hospital discharge is the final stage in an individual’s journey through hospital following the completion of their acute medical care, when they leave an acute setting and move to an environment best suited to meet any ongoing health and care needs they may have. This can range from going home with little or no additional care (simple discharge), to a short-term package of home-based or bed-based care and recovery support in the community, pending assessment of any longer-term care needs (complex discharge). Whether at home or in a community setting, individuals should be discharged to the best place for them to continue recovery (if needed) in a safe, appropriate and timely way.
30. The Trust’s comments about Mr B snr not needing respiratory support relate to his COVID-19 diagnosis.
31. Mr B told us within his complaint that his father had COPD ‘which required to have a portable air compressor’.
32. There is also evidence within the records that Mr B snr did require respiratory support and that he used oxygen at home and upon exertion. The doctor has documented following Mr B snr’s assessment that he had ambulatory [portable] oxygen at home, ‘SOBOE [shortness of breath on exertion] but no more than usual – normally on ambulatory oxygen at home’. On admission the doctor also documented ‘COPD on LTOT [long term oxygen therapy] – uses mainly for walking’.
33. It is clear from the evidence Mr B snr’s respiratory baseline was that he used portable oxygen at home when he mobilised. The records acknowledge Mr B snr used ambulatory/portable oxygen at home prior to admission. Our nursing adviser said that based on this information, the admission plan said ‘oxygen when mobilising’, to mirror the use of oxygen at home. The discharge plan would therefore be to get him back to his same pre-admission baseline.
34. In addition to using portable oxygen at home, Mr B snr was documented as having ‘no carers, being independent with his ADLs [activities of daily living] but receiving help with his shopping. In addition, it is documented in the records that he lived in a bungalow, with one stair to enter the property. Our nursing adviser says that to ensure a safe discharge, staff would need to ensure that Mr B snr was able to continue with this level of independence. If he could not, staff would need to ensure that provisions were in place. Common examples of this include a package of care and equipment within the home.
35. In summary, Mr B snr’s admission documentation clearly outlined his social circumstances, and these remained suitable for him on discharge as he had returned to his pre-admission baseline. In line with the hospital discharge guidance referenced in paragraph REF _Ref182919721 \r \h 29, Mr B required a simple discharge. This is because did not require any additional measures upon discharge, so a risk assessment was not indicated. Mr B snr had the capacity to engage in the discharge planning and expressed he was happy to go home and had no concerns over the discharge arrangements.
36. After carefully considering all the evidence and the comments from our nursing adviser, we consider that staff followed the correct discharge process and followed the simple discharge procedure as per the hospital discharge guidance.
Communication of treatment plans 37. Mr B complains that staff did not take into consideration his father’s anxiety when communicating treatment plans.
38. The NMC Code, outlines the professional standards of practice and behaviour that nurses are expected to follow. Section 13 of the code says that nurses must:
‘13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care
13.2 make a timely referral to another practitioner when any action, care or treatment is required
13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’
39. Within the records, it is clearly documented that Mr B snr was anxious and he was taking Citalopram 20mg for this. Citalopram is used for depressive illness, anxiety and panic disorders. According to the BNF, 20mg is the maximum dose for elderly patients.
40. On 20 October, Mr B snr’s family raised concerns about his anxiety. The records show that staff recognised and addressed the concerns by providing reassurance to Mr B snr at bedtime with an entry stating, ‘remained settled once reassured prior to bedtime’. There are entries in the records showing that the nurses checked on Mr B snr’s wellbeing regularly recording, ‘no concerns or anxieties voiced’.
41. On 23 October, we can see Mr B snr told staff that he was struggling in the side room due to claustrophobia and panic attacks. As we established earlier, being moved to a side room was required due to his positive COVID-19 test, to avoid the spread of infection. The nurses reassured Mr B snr and then raised this with the medical staff for review. This is in line with the NMC standards. Our physician adviser confirmed that there was no indication for additional drug treatment for Mr B snr and general reassurance is all that was required. Thankfully, Mr B snr was able to go home the following day.
42. It is clear staff recognised that Mr B snr had anxiety, and he was taking the maximum dose of citalopram. After careful consideration of the available evidence, we have not identified any failings in the actions of the nursing staff.
43. We acknowledge Mr B snr was an anxious man and being in hospital would have increased his anxiety. We also acknowledge this would have been difficult for Mr B knowing that his father was not comfortable in his surroundings. We hope we have been able to provide some reassurance to Mr B that staff all they could to reassure his father and settle his anxiety.
Admission 2 – 1-14 November 2022 Diagnosis of heart attack 44. Mr B complains that staff did not recognise his father was having a heart attack for three days, blaming his symptoms on high anxiety.
45. On 2 November, Mr B snr presented at the ED with chest pain but predominantly breathlessness. Staff performed an echocardiogram (ECG) (a test that records the heart’s electrical activity, including rate and rhythm) and a troponin blood test (a test measuring proteins in the blood that are released when there is damage to the heart). These tests did not show any evidence of a heart attack. Staff also completed a chest x-ray which our physician adviser confirms showed changes in keeping with pneumonia.
46. The GMC guidance referenced in paragraph REF _Ref185339846 \r \h 21, says doctors must, ‘provide effective treatments based on the best available evidence’. Paragraph 15.a of the GMC guidance also says that doctors must ‘adequately assess the patient’s conditions, taking into account their history’. The Trust diagnosed and treated Mr B snr for COVID-19 pneumonia. We consider this in line with the GMC guidance as staff took into account Mr B snr’s presenting symptoms and previous illness when making a diagnosis.
47. Ward rounds completed on 5 and 7 November reported COVID-19 related symptoms. The ward round on 8 November specifically references that Mr B snr was not experiencing chest pain.
48. On 9 November Mr B snr reported chest tightness so the Trust repeated the ECG which showed some new changes. This prompted a repeat troponin test which came back raised. As the ECG changes and increased troponin levels indicated that Mr B snr was experiencing a heart attack, staff began treatment and transferred him to the Coronary Care Unit.
49. There is no evidence to show that Mr B snr had experienced a heart attack or reported symptoms of a heart attack before 9 November. When Mr B snr reported having a tight chest, investigations into a heart attack began. When tests indicated that he was having a heart attack, treatment started. We consider this to be in line with paragraph 20 of the GMC guidance.
50. We fully acknowledge it was an already stressful situation for Mr B with his father being admitted to the Trust with pneumonia. Learning that his father had a heart attack during his admission will have added to his stress. I hope we have been able to provide some reassurance that staff acted as they should and responded to the changes in his condition promptly.
Discharge arrangements 51. Mr B complains that staff did not complete relevant checks before discharge to ensure his father was discharged into a safe environment resulting in Mr B having to arrange four visits a day from carers as his father was not able to meet his own needs.
52. Section 8 of the NMC Code says nurses must:
‘8.1 respect the skills, experience, and contributions of your colleagues, referring matters to them when appropriate
8.5 work with colleagues to preserve the safety of those receiving care
8.6 share information to identify and reduce risk’.
53. Our nursing adviser said that risk assessing patient is a fluid process that occurs throughout the admission. We can see staff did this and the outcome was a referral to physiotherapy where the patient’s mobility and equipment requirements are assessed. Nursing staff would then follow the therapist’s advice before discharge.
54. In addition to following the advice of the therapists completing the assessments of the patient, nursing staff also are required to listen to the wishes of the patient.
55. Section 2 of the NMC code says nurses must:
‘2.3 encourage and empower people to share decisions about their treatment and care
2.4 respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing and care
2.5 respect, support and document a person’s right to accept or refuse care and treatment’.
56. During Mr B snr’s admission, he was seen by the physiotherapist and given mobility equipment. However, he declined a package of care. As Mr B snr did not want staff to arrange a package of home care, he was provided with a contact number for community care should he change his mind. On 14 November, the day of discharge, staff informed Mr B his father had declined a package of care, and he was given a leaflet with the details of community care should he need it.
57. It is understandable that Mr B is concerned about whether his father was appropriately assessed prior to discharge, as he needed to arrange for a care package for his father shortly after discharge. We have not seen any indication staff did not follow section 8 and section 2 of the NMC Code. Staff referred Mr B to physiotherapists, who offered a package of care. Staff respected Mr B snr’s right to be involved in discharge arrangements and to decline a package of care and ensured he had contact details for community care should he change his mind.
58. We are deeply sorry to hear about how upset Mr B has been and how he has been affected. We extend our condolences to him. We understand how much complaint means to him and thank him for sharing the details. We hope this statement clearly explains the reasons why we will not be considering the complaint further and we regret any further distress this decision may cause.