Stent 23. We know Mrs T remains very concerned with the Trust’s decision to insert a stent in October 2021. We hope to assure her this was a clinically appropriate decision.
24. When Mr T was seen in October 2021, he had been referred urgently to oncologists, before they advised he should be seen immediately in hospital. At that time, he was considered an emergency patient, and his difficulty swallowing was to such an extent he was unable to even take in liquids. Our clinical adviser says in this circumstance, the immediate clinical concern is to resolve these symptoms, to ensure the patient can receive adequate nutrition.
25. The Trust acted in line with NICE CKS guidance. This recommends an urgent upper GI endoscopy for people with oesophageal cancer who have dysphagia. The endoscopy performed in hospital found Mr T’s tumour was causing a stricture (a narrowing of the oesophagus). The tumour was therefore preventing Mr T from swallowing food and fluids. An endoscopic stent was a clinically appropriate decision, to widen the oesophagus with the aim of improving his dysphagia and nutritional intake.
26. The Clinical Endoscopy article we reference earlier, explains endoscopic stent is currently the most common approach to alleviating symptoms for people with a cancerous upper GI obstruction. The article reports findings from six randomised trials, comparing different stents in patients with cancerous oesophageal obstructions. The published results found technical and clinical success rates between 83% and 100%.
27. Due to the size and location of Mr T’s oesophageal tumour, the stent was unable to fully expand. Yet, it opened sufficiently enough to enable him to take in nutrition. Records show that after the stent was inserted, Mr T was able to maintain a liquid diet. This shows us the aim of its insertion was achieved.
28. We know Mrs T is also concerned that the Trust never removed the stent, at any later time. We hope to assure her that this too was clinically appropriate.
29. Our clinical adviser explains that once sited, stents remain in place and are removed very rarely. They say the only occasion a stent may be removed is if a patient is on a plan to receive treatment in the hopes of curing their cancer. For example, a stent might be removed before treatment such as surgery, chemotherapy or radiotherapy can begin.
30. Even then, there are considerable risks with removing stents. Once in place, the tissues surrounding the stent granulate (connective tissue can develop and attach onto and around it), meaning there are associated complications when removing the stent, even if it is considered clinically appropriate, in these rare circumstances.
31. Sadly, these rare circumstances did not apply in Mr T’s case. Investigations found that his cancer had spread, and it was an inoperable and incurable disease. Our clinical adviser explains in this situation, it is not clinically appropriate to ever remove the stent, as it will continue to help meet the patient’s nutritional needs for the remainder of their life.
32. We are assured the decisions to insert the stent and to keep it in place for the duration of Mr T’s life, were reasonable and appropriate clinical decisions. We recognise Mrs T still has these concerns, because she is of the view her husband died from aspiration pneumonia caused by the stent. We hope to provide her further assurance, that we do not find evidence that this was what happened.
33. It is correct that Mr T had aspiration pneumonia, and that this was sadly the cause of his death. Our clinical adviser explains his aspiration pneumonia was a direct cause of his oesophageal tumour, without any direct link to the endoscopic stent. If anything, the stent was preventing or at least delaying the development of aspiration pneumonia.
34. Without the stent, Mr T would have remained unable to swallow even his own saliva. He would have aspirated this (inhaled it into the lungs) and this would have caused him to develop aspiration pneumonia at a much earlier time. The stent itself could not fully prevent aspiration pneumonia from developing, however we can assure Mrs T it had no direct cause to its development in her husband’s case.
NEWS 35. Mrs T complains the Trust failed to act on Mr T’s poor NEWS, or tell his family about his worsening condition, between 6 and 9 February 2022.
36. Our nursing adviser explains that NEWS should be used for the initial assessment of acute illness, and for continuous monitoring of a patient’s wellbeing throughout their stay in hospital. By recording NEWS on a regular basis, the trends in the patient’s clinical responses can be tracked to provide early warning of potential clinical deterioration and a trigger to escalate their clinical care.
37. NEWS measures six physiological parameters: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, and temperature. Scores are then assigned to those six parameters, and in line with NEWS guidance, the total score determines how frequently NEWS should be repeated and whether the patient needs their care escalating.
38. Our nursing adviser has considered the records across Mr T’s admission. They found many occasions where Mr T’s NEWS was not repeated in line with the interval times set within NEWS guidance: five delayed NEWS checks on 7 February, and five on 8 February. This means Mr T’s NEWS was not measured as often as it should have been.
39. From 1am on 9 February, the doctor set NEWS intervals at two-hourly checks. The evidence shows these were carried out every two hours, in line with the clinical instruction.
40. Whilst we find the frequency of Mr T’s NEWS checks before 9 February did not follow guidance, we hope to assure Mrs T we do not see this had any clinical impact.
41. When a NEWS score is high, NEWS guidance says the nurse must immediately inform the medical team caring for the patient, to ensure someone at specialist registrar level attends. On all occasions where Mr T’s NEWS was high, our nursing adviser confirms medical staff at the appropriate level were either already in attendance or were informed. This was in line with NEWS guidance, showing Mr T’s care was escalated to the appropriate level.
42. Both our clinical and nursing advisers confirm that the evidence shows the medical plan was being followed, throughout this period. Our clinical adviser says Mr T was receiving the appropriate treatment, including antibiotics and pain management, throughout this time. This means even with the delays in his observations being taken on 7 and 8 February, from the observations that were recorded, there would not have been any clinical need for additional or alternative action in terms of his care.
43. It remains that the Trust failed to follow guidance in the timeliness of checking Mr T’s NEWS. We can see in response to Mrs T’s complaint, the Trust acknowledged one two-hour delay, and it has appropriately apologised for this. We cannot see the Trust has acknowledged the number of observation breaches we have found, nor said what it might do in future to avoid this recurrence.
44. Whilst this did not cause Mr T an impact, we recognise this has caused Mrs T considerable upset and distress, knowing her husband did not receive the nursing checks as they were due. We set recommendations for the Trust to remedy this.
45. We know how strongly Mrs T feels, that nursing staff failed to realise how poorly Mr T was, in turn not contacting her to be with him when he died. We know how devastating this is for Mrs T and the impact it has had on the family.
46. We can see the two-hourly checks were completed as they should have been, from 1am on 9 February. Records note the call bell was in reach, for Mr T to call for assistance if he had needed to, in between those checks. Our clinical adviser explains whilst Mr T was clearly unwell, he remained stable.
47. Records show both nursing and medical teams conducted several reviews throughout this time. Our clinical adviser says there is nothing clinically to show any deterioration that would or should have suggested Mr T was deteriorating. When Mr T’s NEWS was last taken, less than two hours before he died, this was no different to his NEWS throughout that night. This means we do not see there was anything to have indicated a need to call family, in the time before Mr T died.
48. By this point, Mr T was a metastatic cancer patient with an incurable end-stage disease, and his care was not for escalation outside of ward-based care. Our clinical adviser says there was nothing further that was clinically indicated in terms of his treatment, and he was already receiving the appropriate treatment for his circumstance.
49. Very sadly, what happened to cause Mr T’s death was a very acute event that took place in the two hours between his nursing NEWS checks. We do not find anything to show this was predictable or preventable.
Nursing care 50. Mrs T complains about the nursing care given to her husband during this admission. She says family reported he looked ‘unkempt and dirty’ when they saw him in hospital, and nurses did not help Mr T with telephone calls.
51. The records make clear that Mr T was struggling with his breathing. Our nursing adviser says it is clear Mr T was exhausted during this admission, having consistently high respirations. This would have impacted on his ability and desire to self-care, and ability with activities such as making and receiving personal calls.
52. NMC guidance sets out the following nursing standards:
‘1.16 demonstrate the ability to keep complete, clear, accurate and timely records
4.1 observe, assess and optimise skin and hygiene status and determine the need for support and intervention
4.3 assess needs for and provide appropriate assistance with washing, bathing, shaving and dressing
4.5 assess needs for and provide appropriate oral, dental, eye and nail care and decide when an onward referral is needed.’
53. Whilst nursing records note Mr T was independent with his own hygiene and oral care needs, we find indications that he may have needed support. An entry on the morning on 8 February notes Mr T declined a skin check. Our nursing adviser says nursing staff should have questioned if this was due to exhaustion and ensured that he received support if needed.
54. There is no indication that nursing staff offered support to Mr T. Due to his exhaustion, in line with NMC guidance we think nursing staff should have offered support in meeting his hygiene needs, documenting that they had done so, including any times he declined.
55. Considering Mr T’s difficulty breathing, our nursing adviser says nursing staff should also have assisted with personal phone calls. NMC guidance contains standards supporting this:
‘1.12 demonstrate the skills and abilities required to support people at all stages of life who are emotionally or physically vulnerable
1.13 demonstrate the skills and abilities required to develop, manage and maintain appropriate relationships with people, their families, carers and colleagues
2.4 support and manage the use of personal communication aids.’
56. We can see in response to Mrs T’s complaint, the Trust acknowledged the distress the family experienced, and apologised for the upsetting telephone call in question. We cannot see the Trust has acknowledged the lack of offered nursing assistance to Mr T for his personal hygiene needs, nor said what it might do in future to avoid this recurrence.
57. We think this has Mrs T considerable upset and distress, knowing her husband did not receive this nursing care, and seeing and hearing from him in a distressing way during his final admission. We set recommendations for the Trust to remedy this.