Hydration
14. Miss U complains the Trust did not provide her mother, Mrs R, with adequate hydration. She says this caused her mother to suffer from thirst and this was distressing for her to witness.
15. We considered whether staff managed Mrs R’s hydration in line with guidance during her admission.
16. NICE guidelines say clinicians should assess and manage a patient’s fluid and electrolyte needs as part of every ward review. It says clinical monitoring should include status and trends in fluid balance charts.
17. NMC guidelines says nurses should observe, assess and optimise nutrition and hydration status and determine the need for intervention and support. It also says nurses should record fluid intake and output and identify, respond to and manage dehydration or fluid retention.
18. The records show on 25 October at 10.10am Mrs R was identified as having a low urinary output while she was in the emergency department. Low urinary output can be a sign of dehydration. However, there was no documented plan to monitor or to provide any support with fluid intake. When monitoring did commence, the fluid input and output was not documented properly. The Trust’s records keeping is therefore not in line with the NMC guidance.
19. There is no documented plan regarding Mrs R’s hydration needs, which is a failing. The assessment of Mrs R’s hydration it is not documented properly. We have gone on to consider the actions staff took in relation to managing Mrs R’s hydration. To do this, we have first considered what actions they took in response to her reduced oral intake.
20. The Trust’s policy says the best way to administer fluids is orally, but that on some occasions, due to illness, it may be necessary to consider other routes. The NMC Code says nurses must make sure people’s physical, social and psychological needs are assessed and responded to.
21. It appears staff did try and encourage Mrs R to take some fluids orally. On 25 October at 10.22pm they gave her 100ml of water, but she spat some out. The next day at 4.36am staff gave Mrs R 20ml of water and encouraged her to take small sips so she did not choke.
22. Our nursing adviser says this approach was not enough to increase Mrs R’s oral intake. The records show Mrs R was drowsy at times, often found swallowing difficult, and had a BiPaP mask on. A BiPaP mask is a type of non-invasive ventilation that helps the patient breathe. Because of this, her oral intake appears to have remained low.
23. We acknowledge here this could partly be because of the failings in record keeping, meaning staff may have given Mrs R fluids and not recorded this.
24. Because of Mrs R’s low oral intake, in line with the NICE guidance and the Trust’s policy, staff should have considered providing fluids via a different route.
25. At 6.25pm on 26 October, staff gave Mrs R 1 litre of fluids intravenously. At 8.07pm, they gave her a further litre of intravenous fluids. Our nursing adviser explained that these were prescribed to be given slowly, to prevent fluid overload.
26. There is some evidence staff were assessing and managing Mrs R’s hydration needs in line with the NICE guidelines. While evidence is lacking, we can see some evidence that oral intake was encouraged, and when this was not successful, fluids were provided by an alternative route. This was in line with the Trust’s policy.
27. We acknowledge here that staff had to balance Mrs R’s hydration needs with her fluid retention. We can see evidence that they tried to achieve this, even if the management plan was not documented.
28. As set out above, the Trust identified Mrs R had a low urinary output when she was in the emergency department. Staff gave her frusemide intravenously on 25 October at 1.38pm. Furosemide is a medication to help treat fluid retention by increasing urine output. Fluid retention is a collection of fluid in the spaces between the cells of the body, when fluid leaks out of damaged cells. One of the causes of fluid retention is heart failure, which Mrs R had.
29. We can see that following this, Mrs R’s urinary output increased. Between when staff catheterised Mrs R on 25 October at 11.32pm, and when emptied the catheter bag the following morning at 6.30am, Mrs R passed 1,200ml urine. Our nursing adviser explained this increase in urine output was an improvement.
30. We can also see that on 26 October, the Trust omitted two doses of oral furosemide. It is documented this was for ‘clinical reasons’. Our nursing adviser explained this was likely because furosemide could further increase the risk of dehydration.
31. Due to the lack of records, it is difficult to know whether the IV fluids were prescribed at the right time, and whether they were enough to prevent Mrs R being dehydrated. Our nursing adviser said due to the lack of records, it is not possible to identify at what point during Mrs R’s admission intravenous fluids could or should have been commenced.
32. Miss U has told us how distressing it was to see her mother feeling thirsty. We acknowledge how upsetting it must have been to see her mother so poorly and that worrying that she wasn’t being given enough fluids would only have compounded that distress.
33. There are failings in record keeping. There is no documented plan regarding management of Mrs R’s hydration. As set out above, we cannot say now whether IV fluids could or should have been started sooner, or whether it is likely Mrs R was dehydrated.
34. This uncertainty is an injustice for Miss U, and the ongoing uncertainty is likely to have caused her prolonged distress. We have made recommendations in respect of this, below.
DNACPR
35. Miss U says staff did not communicate with her its decision to put in place a DNACPR. She says witnessing staff not performing CPR on her mother at the time of her death caused her enormous distress and it has impacted her mental health.
36. GMC guidance says if cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful in restarting breathing and circulation. It also says discussing, making and recording a decision in advance not to attempt CPR can help to ensure that the patient dies in a dignified and peaceful manner.
37. The Resuscitation Council guidance says it is a clinical decision regarding whether CPR is provided. This means that doctors will decide whether to place a DNACPR, not the patient or their relatives. It says healthcare professionals should discuss and communicate CPR decisions to patients, and those close to them. These discussions should be open and honest, and use clear and unambiguous language. Healthcare professionals should also check the understanding of those involved in the discussion.
38. The Resuscitation Council guidance also says good documentation should include the details of any discussions about the decision with the patient, and with those close to them. This should include what information was offered to the patient and those close to them.
39. Mrs R’s medical records from a previous admission in June 2020 document a discussion about DNACPR. This is quoted in the medical records from this admission. This shows on 25 June 2020, staff had discussed DNACPR with Mrs R, and it appears she was agreeable to it at that time.
40. Our physician adviser explained that this form, completed in June 2020, expired in June 2021. This meant there was no active DNACPR in place when Mrs R was admitted to the Trust on 25 October 2021.
41. The records show staff completed a new DNACPR form on 25 October at 11.07am, while Mrs R was in the Emergency Department. The DNACPR form shows Mrs R was not involved in the DNACPR decision, but the part that says ‘agreed for decision to be discussed with relative/partner’ is completed as ‘yes’.
42. This is also documented in the notes in an entry timed at 11.19am. This says ‘DNACPR instituted in discussion with patient and her daughter’.
43. The evidence here is conflicting. Both the written notes and the form suggest the DNACPR decision was discussed with Miss U. It is not clear whether or not it was discussed with Mrs R. It is unclear how staff decided Mrs R agreed for the decision to be discussed with Miss U if it had not discussed this with Mrs R, as suggested on the form.
44. We can see from the records on 27 October, prior to Mrs R’s death, that Miss U was keen for treatment to continue, rather than end of life care to be provided. The records show a nurse asked a doctor to review Mrs R early on 28 October, as she thought Mrs R had died.
45. At this time, Miss U asked for resuscitation to be carried out, and the doctor informed her that the DNACPR was in place. The doctor noted Miss U said Mrs R would not have wanted the DNACPR, and that Miss U was not aware this was in place.
46. There is also documentation from 27 and 28 October, which reflects discussions staff had with Miss U about the DNACPR after Mrs R had died. In this, they document that Miss U recalled a conversation with the doctor in A&E, and that he stated ‘we may need to started thinking about DNACPR in the future’. The Trust documented that Miss U did not think she had been definitively told a DNACPR had been introduced.
47. Miss U told us her mother had not been in a fit state to have a conversation about whether she would have wanted CPR. She also said that she had not agreed to the DNACPR.
48. Staff failed to clearly communicate the decision about the DNACPR with Miss U. We recognise the GMC guidance says it is a clinical decision whether to provide CPR, and it should not be offered if there is no reasonable prospect of success. Our concern here is around the discussion the Trust had with Miss U, and the documentation of this, rather than the decision reached.
49. Faced with the conflicting accounts here, it is difficult to know if the discussion about not attempting CPR took place. What we can say is that if a discussion did take place, there is no evidence to show what was discussed, or what information was shared. This is not in line with the Resuscitation Council guidance.
50. Considering the evidence available, if the discussion did take place, we do not think it involved clear and unambiguous language. We also do not think staff checked Miss U had understood what they had told her. Again, this is not in line with the Resuscitation Council guidance.
51. Given this, it is entirely understandable that Miss U experienced significant distress when she asked for CPR to be undertaken and staff refused. This was at an already extremely distressing time for Miss U, and this exacerbated her distress.
52. Miss U has told us that her mental health has been impacted by these events, and that this continues to impact her everyday life. We can understand why these events were so distressing for Miss U, and why they have had a lasting impact on her. We are making recommendations in respect of this, below.