Bisoprolol and ramipril medication
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 the Trust was wrong in how it treated Mr A and the medication it gave to him.
17. Mrs W complains the Trust did not check Mr A’s medical record and inappropriately gave him a large dose of bisoprolol and ramipril medication, despite his GP having stopped this several months earlier.
18. NICE guidance, acute heart failure: diagnosis and management says ‘1.5.2 start or restart beta-blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction (heart failure in the left ventricle)’ and ‘1.5.4 offer an angiotensin- converting enzyme inhibitor (or angiotensin receptor blocker if there are intolerance side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure and reduced left ventricular ejection fraction (blood pumped out with each contraction)’.
19. Our cardiology adviser explained that ramipril and bisoprolol are mainstay medications used to treat patients after a heart attack. Mainstay of treatment in medical terminology means the most important or fundamental approach to treat a problem or illness.
20. Mr A suffered a heart attack in April 2021 and July 2021. He was admitted to the Trust on 13 July 2021. The previous events sadly weakened his heart’s ability to pump blood to vital organs. The Trust’s responses explained it re-started Mr A’s medications due to his heart failure.
21. Mrs W said the family were told the doctor gave the medication and did not check Mr A’s medical records. From review of the medical records, we can see the Trust was aware the GP had stopped bisoprolol and ramipril. The medical records note on 13 July at 4.20pm Mr A’s GP had stopped the medication. The medical records note on 14 July at 11.15am ‘GP stopped ACE and betablocker due to dizziness’.
22. Mr A had poor heart pump function. Our cardiology adviser explained he would benefit from treatment with ramipril and bisoprolol in line with NICE guidance. Upon admission, his heart rate was high and bisoprolol was used to slow the heart rate. Ramipril was used to reduce the demand on the heart by reducing the pressure load on the heart and prevent the heart from deforming. Our cardiology adviser explained that doses are often adjusted according to the patient response. They said low blood pressure or dizziness alone are not indications to stop these medications.
23. Mrs W raised concerns that the Trust gave atropine and glucagon medications to reverse the effects of the beta blockers. We have reviewed Mr A’s medical records and his death certificate which said at the time of cardiac arrest. The Trust gave medication to reverse the effects of the beta blockers and Mr A’s heart rate improved. This is supported by Mr A’s records. Mrs W’s concern is her father needed this because of the bisoprolol and ramipril.
24. The BNF outlines bisoprolol is known to slow the heart rate and ramipril may cause a lowering of blood pressure.
25. From review of the medical records, staff were monitoring Mr A’s heart rate at the time of his deterioration on 14 July. This shows Mr A’s heart rate was around 80bpm (beats per minute) at 5.02pm. The bradycardic event (when the heart beats fewer than 60 times per minute) happened around 5.12pm. His heart rate was then recorded at 40 to 50bpm until 6.10pm when it was noted to speed up to 80bpm.
26. Our internal adviser explained when someone has a cardiac arrest associated with a slow heart rate, doctors will try to treat what they can to remedy the situation. In this situation where it is an emergency, they give all the treatments that may potentially be helpful. As bisoprolol is known to cause a slow heart rate then it would be reasonable to give treatment to try to reverse the effects of it. In this case the Trust gave Mr A atropine and glucagon, as the BNF explains they are used to speed up the heart rate.
27. We understand the events have been tragic and upsetting for Mrs W and her family. We appreciate it must have been worrying and confusing to learn he had re-started taking medication which was previously stopped. We can understand how this caused concern. There are no indications of failings in the Trust’s decision to give the medication again given Mr A’s presentation.
Visiting
28. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already reflected on the complaint about visiting.
29. Mrs W says only two family members were able to visit Mr A when he was at the end of life. This left nine family members denied access and instead saying goodbye via video messaging, even though they were metres away.
30. At the time of the tragic events, the Trust had strict guidelines in place due to the COVID pandemic. This was regarding social distancing and NHS guidelines about visiting which the Trust had to abide by.
31. The NHS guidance, vising healthcare inpatient settings during COVID 19 pandemic, principles gave guidance for visiting. It allowed one close family contact at a patient’s bedside. This also referred to visiting at end of life. It said ‘a compassionate approach is essential on balancing the importance of close family and others important to the dying person being able to spend precious time with them and say goodbye, with the need to manage infection risk and maintain safety of the visitor, staff and other patients. Organisations should use their own risk-based assessment to decide to what extent more relaxed visiting arrangements can be facilitated’.
32. We have seen a copy of the Trust’s SOP. It says ‘no visiting is permitted for any patients except for compassionate reasons when a patient may be dying imminently. This is generally limited to one visitor only and must be discussed with the nurse in charge prior to agreement’.
33. Mr A’s medical records show the Trust told Mr A’s family members about his poor clinical condition. On 14 July at 6.40pm, the Trust updated multiple family members. The Trust said that Mr A had suffered a large ischemic event (reduced blood flow to part of the body) and a high chance it was not survivable. The family were upset and only two people would be able to visit.
34. The Trust’s complaint response said the ward was not restrictive and did not refuse anyone entry to a deceased or dying relative. It also said it wanted to assure Mrs W it always tries to ensure that these stressful times are made as easy as possible for families, and it is its expectation that staff act in a caring and compassionate manner. It explained Mrs W’s complaint had highlighted this was not their experience and it was sincerely sorry for additional upset this has caused.
35. The Trust’s further response said the nurses on duty at the time would have been doing their best to abide by guidelines and show compassion at a difficult time for the family. It acknowledged reasonable practice would have been to allow people in to see their loved one in pairs and allow everyone a chance to visit. It said it was sorry for the distress and upset caused by the family not being allowed in together.
36. We understand it must have been extremely upsetting for the whole family being restricted on the number of people who could spend time with Mr A at the end of this life. It is understandable that this would add distress at an already very upsetting time. There were limits on the number of family members allowed in a patient room at any one time and this was in accordance with the Trust’s own COVID SOP and NHS guidance. We understand this had an impact on Mr A’s family. The Trust had to abide by the rules that were in place at the time.
37. It is our view that there is an indication that the Trust did not communicate the process as clearly as it could have done. Mrs W and her family were of the view that only two family members could visit at all, not just at one time. We understand that this left some family members unable to see Mr A to say goodbye.
38. We have asked the Trust about its communication. It said following COVID it has a better understanding of the virus and vaccinations in place and hopes that it would never have to restrict end of life visiting in the future. The steps it took at the time were governed by national guidance and a regional approach to ensure all local hospitals were offering an equitable approach. It has now shared learning with its staff and this also included information around zoom calls, use of family liaison teams, post bereavement telephone calls and letters to loved ones. It accepts that none of this will ever replace the fact that families may not be able to be with their loved ones.
39. Our Principles for Remedy say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
40. We understand this was a very upsetting time for Mrs W and her family when they wanted to spend time with Mr A at his end of life. We have also noted the strict rules in place at the time around COVID and visiting. We are of the view that the Trust has reflected on this, apologised and has already done enough to learn from these events. This is in line with our Principles of Remedy and NHS Complaints Standards.
41. We recognise how distressing this has been for Mr A, Mrs W and her family. We hope we have explained our decision clearly.