DNACPR
16. Doctors should follow the ‘decisions relating to cardiopulmonary resuscitation’ guidelines (the DNACPR guidelines) when making decisions about whether to resuscitate someone. This guidance says that considering and making anticipatory decisions (a decision made before the problem happens) about whether or not to attempt CPR is an important part of care for anyone who is at risk of cardiorespiratory arrest (also known as a ‘heart attack’).
17. Mr A had chronic COPD, and this put him at risk of cardiorespiratory arrest. Therefore, it appears in line with the DNACPR guidelines to have considered whether or not the doctors should attempt to resuscitate him if this happened.
18. The DNACPR guidelines also say that decisions about CPR are best made in advance, before a crisis necessitates a hurried decision. The decision is ultimately a medical decision and agreement with the patient and/or family is not required for implementing a DNACPR order.
19. The DNACPR guidelines outline that clinicians should follow these steps when deciding whether to implement a DNACPR order:
• consider whether there is a possibility of cardiac or respiratory arrest • if this risk is present, the doctor should consider if CPR would likely be successful • if CPR would be unlikely to succeed, the doctor should discuss this with the patient and explain the need for a DNACPR order on these clinical grounds • if the patient or their family does not accept this decision, a second opinion should be offered.
20. On 25 August a medical SPR (an experienced resident doctor) reviewed Mr A and documented a discussion with him about CPR. This appears to be good practice as Mr A had a condition that was deteriorating to the point that CPR would be unlikely to benefit him. The SPR documented that Mr A had mental capacity and that he agreed with the decision. The SPR then completed the DNACPR form and a ceiling of care for Mr A, which is a plan of what treatment would be provided if his condition deteriorated further.
21. The evidence indicates that the DNACPR decision was reached following the process outlined in the DNACPR guidelines and that Mr A agreed with this decision.
22. Mr A’s medical records reflect that he had also agreed to discuss the DNACPR with his family. There is no record of any disagreement with the DNACPR decision in August. The first documented instance of disagreement was on 15 October.
23. There is no evidence to indicate that the Trust agreed to rescind Mr A’s DNACPR in August or at any other point after it was implemented. This was a medical decision that appears to have been made in line with the DNACPR guidelines, with no disagreement from Mr A or his family documented at that time. There are no indications of service failure in relation to this decision.
Catheter care
24. In line with the NMC Code, nurses should deliver the fundamentals of care effectively and provide treatment without delay.
25. With regards to changing Mr Salmon’s catheter, how frequently this should have been changed depended on the type of catheter used. A short-term catheter should be changed every four weeks, whereas a long-term catheter should be changed every 12 weeks.
26. On 26 June the Trust inserted a catheter for urinary retention. This was documented as being a short-term catheter, which should be changed every four weeks. Mr Salmon was discharged from hospital on 16 July, before this four-week period elapsed, with a referral to the trial without catheter clinic in the community.
27. Mr Salmon then attended the ED again on 25 August because of urinary retention. A long-term catheter was inserted whilst he was in the ED. This catheter did not require changing for 12 weeks. The next recorded catheter change was on 5 October, when a short-term catheter was inserted. The catheter was changed again on 23 October. Both these catheter changes took place within the required timeframes and the evidence indicates the fundamentals of care were delivered effectively and without delay, in line with the NMC Code.
28. There are two recorded instances where Mr A’s catheter became blocked. This occurred in the community, and he attended the ED to resolve the issue on 11 September and 5 October. On 11 September, the catheter was flushed to resolve the blockage and on 5 October his catheter was changed to resolve the blockage. This appears to be in line with the NMC Code. There are no other documented instances of Mr Salmon’s catheter becoming blocked.
29. Regarding the complaint that Mr A’s catheter was not removed before his discharge in October, our nurse adviser explained that this was appropriate because he was a vulnerable adult with a history of urinary retention. They explained that given the risks associated with urinary incontinence causing moisture lesions and skin integrity, it would have been in his best interests to manage his continence with a urinary catheter at home. This was especially as Mr A had been discharged a couple of months earlier, with a referral to the trial without catheter clinic, which had failed and resulted in readmission to hospital.
30. There are no indications of service failure with regards to the frequency of changing Mr A’s catheter, resolving blockages, and the decision to discharge him home without removing the catheter in October.
Funding 31. NICE guideline NG27 outlines what NHS services should do to plan for discharge when people have social care needs. These guidelines state that discharge planning should commence upon admission to hospital, and the patient’s family/unpaid carers should be involved in discussions about this, where appropriate.
32. Under The Care and Support (Preventing Needs for Care and Support) Regulations 2014, intermediate care can be provided by the local authority free of charge for up to six weeks (known as reablement). Longer-term care arrangements are subject to funding assessments by the local authority. This means that decisions around who pays for community social care are usually made by the local authority, not NHS Trusts. When a patient is identified as potentially eligible for Continuing Healthcare (CHC) funding, the local authority will refer the patient to the local Integrated Care Board for an assessment.
33. Mr A was admitted to hospital on 3 October. On 4 October the nurses documented a discussion around him requiring carers at home when discharged from hospital. This indicates that the Trust was actively planning his discharge from the point of admission, which was in line with NG27. He was referred to the ROCKET team on 5 October to support with his discharge planning.
34. On 12 October the nursing staff documented a plan for Mr A to be supported by the local authority’s Reablement Team. This forms part of the six weeks of social care that is free of charge following discharge from hospital. The notes show this team had confirmed it could support Mr A’s discharge on 13 October. The nursing notes also reflect he was referred to the District Nursing service for catheter care in the community on 12 October.
35. Mr A was discharged home on 13 October. There was no concern or discussion around funding for care associated with this discharge as the Reablement Support was fully funded by the local authority.
36. Mr A was readmitted to hospital the following day. A note made by the nursing team, following discussion with Miss L, reflects the family’s concerns about the social care provided by the Reablement Team. The nurse documented strict instructions not to discharge Mr A without an adequate package of care. This indicates discharge planning had commenced again upon admission to hospital and that the Trust was engaging with Mr A’s family and listening to their concerns.
37. On 21 October the Trust held a meeting with Mr A and his next of kin to discuss his discharge plan. During this meeting the team documented that social services needed to complete a financial assessment for this care. The Trust also agreed to ask someone from the Discharge Team to discuss finances with Mr A. It appears this did not happen, however, as there is no documented record of a discussion. The Trust also planned for the equipment Mr A would need at home.
38. We recognise discussions around funding are very distressing for families. The Trust had no power or influence over whether Mr A would need to fund his social care. It was appropriate for the Trust to advise Mr A and his family that the local authority would need to discuss funding with him.
39. Over the following days, the staff liaised with the Discharge Team and arranged for the care and equipment Mr A needed. There was a small delay in organising delivery of the equipment. Support from the Reablement Team was to be provided on discharge; however, Miss L raised concerns that the care would not be sufficient.
40. On 27 October the Trust’s Occupational Therapy (OT) team documented a discussion around Mr A needing a package of long-term care as his needs were variable. The Reablement Team could not provide this support in the long term, and the Trust’s OTs expressed their view that Mr A needed permanent, long-term care arrangements.
41. The following day, the short-term care with the Reablement Team was cancelled with a view to arranging a longer-term package of care for Mr A. The OT team documented a discussion with Mr A who was angry about having to pay a lot of money for something, but that he would not tell the staff what this was about.
42. Later that day the staff documented a phone call from Miss L where she told them she had received a telephone call where she was quoted £1,500 per week for Mr A’s care. She told the staff she did not know who made this call to her.
43. On 29 October the team documented that Mr A and his family had decided to reject the package of care offered and that they wanted him to come home with support from his family. The family told the Trust they would then source their own carers. Mr A was due to be discharged the following day; however, this did not happen because his condition deteriorated. At this point, he was not safe to be discharged home and, shortly afterwards, he was placed on end-of-life care. Mr A, sadly, died a few days later.
44. The evidence indicates there was no delay caused by funding arrangements. Funding for social care is determined by the local authority and the local authority appears to have been responsible for identifying whether Mr A was entitled to funded care. We do not know whether he was or was not entitled to CHC funding as no assessment for this took place. It appears appropriate that the Trust told Mr A and his family that he may need to pay for social care that extended beyond the Reablement Support funded by the local authority.
45. We know someone called Miss L on 27 October about funding, but we do not know whether this was someone from the Trust or someone from the local authority. In any event, this does not appear to have delayed Mr A’s discharge. There was a slight change in the discharge plan from Reablement Support to longer term care, following concerns raised by Miss L, but did not appear to be funding related.
46. The evidence indicates there were no delays in discharging Mr A due to the Trust incorrectly advising him he would have to self-fund his social care. The Trust appears to have planned Mr A’s discharge in line with NG27, and changed the plan when concerns were raised by Mr A’s family. Sadly, his condition deteriorated before he could go home.
Unsafe discharge 47. Safely discharging a patient is a clinical decision that includes considering whether the personal is medically fit for discharge and whether this would be safe due to other factors, for example unmet social care needs.
48. Doctors assess whether a patient is medically fit for discharge and should ensure they adequately assess the patient’s condition. The complaint here is that Mr A was not medically fit for discharge due to an untreated chest infection.
49. There is no specific measure as to whether someone is medically fit for discharge, and this is based on the judgement of the doctors at the time. Our physician adviser told us the best evidence we have as to whether Mr A was medically fit for discharge is his NEWS2 scores and the documented clinicians’ reviews of his condition.
50. NEWS2 is a tool published by the Royal College of Physicians to help doctors identify when a patient may be deteriorating and becoming seriously unwell. The guidelines for this tool recommend that it be used to assess a patient’s acute illness severity. This means that these scores give us a good indication of how unwell Mr A was at that time.
51. Mr A’s NEWS2 scores were increased due to his supplemental oxygen needs. It is recognised that chronic conditions, such as COPD, may increase NEWS2 scores but may not represent a deterioration or severe illness. The guidelines say clinicians should use their clinical judgement in these cases.
52. Mr A’s NEWS2 scores were consistently stable leading up to his discharge and did not indicate he was severely unwell or that he was deteriorating. He was reviewed by the consultant in a ward round on 12 October and was documented as being stable and ready for discharge the following day.
53. There were no indications of infection present in Mr A’s physical observations, such as a raised temperature, that would indicate he had a chest infection. Our physician adviser explained that, based on the medical evidence, it appears more likely than not Mr A deteriorated from his previously stable condition and required readmission to hospital the following day. This is not uncommon for older patients with chronic respiratory problems, like Mr A, and does not necessarily indicate the discharge was unsafe or inappropriate.
54. The deterioration is evidenced by his NEWS2 scores being seven and eight when readmitted on 14 October, a marked increase from three the day before. This indicates a sudden deterioration occurred post discharge, rather than him being too unwell to be discharged the day prior.
55. We can understand why Miss L was so concerned. A sudden deterioration leading to readmission to hospital can raise questions about whether the person should have been discharged in the first place. The medical evidence indicates that Mr A was medically fit for discharge on 13 October and there are no indications of service failure.
Inappropriate social care
56. Miss L says the Trust arranged for a package of at home social care, in November 2021, that was not appropriate for A’s condition and care needs.
57. There is no evidence of any package of care being arranged in November 2021. Mr A and his family rejected the package of care proposed in October, and on 31 October Mr A was identified as being at the end of his life. There were no plans to discharge him following this and he was assessed as being too medically unstable to transfer to another location.
Hydration and nutrition 58. NICE guideline CG32 (nutrition support for adults) outlines what the Trust should have done to manage Mr A’s nutrition needs. These guidelines outline that the Trust should have screened him for malnutrition on admission to hospital. Screening should assess body mass index (BMI) and percentage of unintentional weight loss. Using a tool, such as the Malnutrition Universal Screening Tool (MUST), is recommended but not required.
59. There are no clinical guidelines on managing hydration needs in general. However, the Care Quality Commission’s guidelines on the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 14 (meeting nutritional and hydration needs) state that patients should have their hydration needs assessed and reviewed when a patient is required to stay overnight at a healthcare facility.
60. Mr A’s medical records reflect his hydration needs were assessed on each admission to hospital, and he was identified as not requiring support to drink oral fluids. His food charts reflect he was provided with regular hydration and no concerns were raised by any members of the clinical team, Mr A or his family about his hydration.
61. NICE guideline CG32 states that patients should be identified as malnourished if:
• they have a BMI of 18.5kg/m² • unintentional weight loss of more than 10% of their body weight in 3-6 months • a BMI less than 20 kg/m² and unintentional weight loss greater than 5% within the last 3 to 6 months.
62. The guidelines state nutrition support can only be given to patients with their consent if they have mental capacity. This means that clinicians cannot force patients to accept the nutritional support offered to them.
63. When Mr A attended the ED on 25 June 2021, his BMI was 17kg/m². He was screened using the MUST tool on admission, in line with NICE CG32, and was assessed as being at high risk for malnutrition.
64. The same day, the nursing team sent a referral to the dietetics team for input into managing his risk of malnutrition, and on 28 June the Trust commenced a dietetic prescription for Mr A to have nutritional supplements twice daily. The nurses also completed food charts for Mr A and he was discharged on 28 June. His nutrition needs appear to have been managed in line with NICE CG32.
65. When Mr A was admitted to hospital on 10 July the nursing team completed a MUST assessment and noted his BMI was 16.4kg/m². The team identified he was at high risk of malnutrition and referred him to the inpatient dietetics service that same day.
66. On 11 July the nursing team commenced and maintained food charts for Mr A to monitor his intake and documented that they were encouraging him to eat and drink.
67. On 12 July the dietetic service tried to assess Mr A, but he declined to engage with them and told them he would contact the community team when he was at home. The dietician outlined a plan for a snack menu and additional puddings with milky drinks to increase his intake until discharge. He was discharged from hospital on 16 July. During this admission Mr A declined nutritional support, but the assessment from the nursing team appears to be in line with NICE guideline CG32.
68. On 25 and 27 August, and 11 and 12 September Mr A had some short admissions to the ED. He was discharged shortly after each presentation. There was no opportunity to manage his nutritional needs during these admissions.
69. On 3 October Mr A was admitted to hospital again. The nursing team completed a MUST screen that day which identified his BMI was 16kg/m² and he was at high risk of malnutrition. The nurses commenced and completed food charts for Mr A and referred him to the dietetics team.
70. The Trust’s dietetics team came to assess Mr A on 5 October. They noted Mr A had not been engaging with the community dietetics team and looked ‘emaciated’. The dietician prescribed nutritional supplements, instructed the nurses to maintain food charts, weigh Mr A weekly, and provide a snack menu. Three different nutritional supplements were prescribed that day.
71. When Mr A was weighed again on 10 October, he had lost a significant amount of weight. The nursing team asked the dietetics team to review him again, which happened on 12 October. The dietician queried the accuracy of the weight loss but noted he remained very frail looking. They referenced the nutritional prescription chart, and that Mr A had refused all supplements offered to him. They also noted that his food charts indicated he was not eating all of his meals. The dietician asked the staff to continue encouraging him to accept the supplements and added an additional supplement option to his prescription. Mr A was discharged home on 13 October.
72. Mr A was readmitted to hospital the following day and the nursing team completed a MUST assessment again. He was identified as high risk of malnutrition due to his low weight, and a dietician reviewed him. The dietician set up a plan of nutritional supplements, snacks, and milky drinks.
73. The nurses recorded his food intake and documented that he consistently refused the nutritional supplements offered to him. He also refused the snacks. Although the nurses documented encouraging eating and drinking, they were unable to force Mr A to do so.
74. The evidence indicates that on each admission Mr A’s nutrition needs were screened using the tool recommended by NICE CG32. The nurses were actively monitoring his nutritional intake and, on each admission, referred him to the Trust’s inpatient dietetics team. He was also referred to the community dietetics team on discharge, but did not answer their telephone calls.
75. Mr A did lose a lot of weight, but the Trust did not need to investigate this further because it knew why this was happening. The dieticians documented he was losing weight because his food charts consistently showed he was not eating enough, and he was refusing the nutritional supplements prescribed. The Trust put several plans in place to try and improve his caloric intake, which Mr A consistently refused. Because he had mental capacity, this was a decision he was entitled to make and the Trust had to respect his decision to decline this support. There are no indications of service failure.
End of life care 76. Mr A’s medical records indicate that his clinical condition began to deteriorate suddenly on 30 October. The clinician’s notes from 29 October indicate his condition was stable and they were planning to discharge him home. When reviewed by a clinician on 30 October, his oxygen requirements had escalated and he was no longer well enough to go home.
77. On 31 October the clinicians identified that Mr A was entering the final days of his life.
78. NICE guideline NG31 (care of dying adults in the last days of life) outlines what care should look like in the final days of a person’s life. The guidelines say doctors should ‘avoid undertaking investigations that are unlikely to affect care in the last few days of life unless there is a clinical need to do so’. These guidelines also recommend that when a person may be entering the last days of life doctors should ‘review their current medicines and. . . stop any previously prescribed medicines that are not providing symptomatic benefit or that may cause harm’.
79. In line with these guidelines, when a person is identified as in the final days of their life, clinicians should avoid investigations that are unlikely to affect the direction of care and should stop medications that are not providing symptomatic benefit. This should be discussed with the patient and their family where appropriate.
80. Mr A’s records indicate the clinical staff spoke with him and his family about his care in the final days of his life. On 31 October a doctor documented a discussion with Miss L and Mr A about him not tolerating the non-invasive ventilation and that they should take a comfort-based approach. The doctor documented a plan to commence end of life care, provide anticipatory medications for comfort, and stop any further physical observations and blood tests. The doctor documented that Miss L agreed with this.
81. Mr A’s prescription charts show that the clinicians stopped some of Mr A’s medications, but his nebulisers and inhalers for his COPD continued to be prescribed and offered to him. He was also prescribed medications for agitation (midazolam) and pain relief (morphine), and the records show these were administered.
82. The doctors recommended stopping physical observations and blood tests, which appears appropriate and in line with the guidelines as these can cause discomfort in the final days of life. The updated DNACPR for 30 October also indicates that the plan was to continue most active treatment, with the exception of invasive interventions to prolong his life and resuscitate him.
83. The evidence indicates that the Trust did not withdraw all treatment in the final days of Mr A’s life and the care provided appears to have been in line with NICE guideline NG31.
84. NICE guideline NG31 also says that ‘while it is normally possible and desirable to meet the wishes of a dying person, when this is not possible explain the reason why to the dying person and those important to them’.
85. Although Mr A wanted to die at home, his end of life care plan indicates he was not medically stable enough to be transferred to a different location. On 31 October a doctor documented a detailed conversation with both Mr A and his family about his end-of-life care. The Trust also asked the Palliative Care team to review Mr A to offer support to him and his family in the final days of his life. This team reviewed Mr A on 2 November and documented that they explained to Mr A’s family that he was likely at the end of his life. There was nothing documented regarding a request to die at home, and the entry from the Palliative Care team on 2 November stated that the family ‘did not appear ready to accept’ Mr A was dying at that time.
86. Mr A’s medical records indicate that the clinicians communicated with him and family about his end-of-life care. There was no documented communication from Mr A and his family that he wanted to die at home. The evidence also indicates that the plan was communicated to Mr A and his family and that all were in agreement with the plan.
87. Mr A was not medically stable enough to transfer to a different location and there is no evidence that he or his family requested this. The Trust’s Palliative Care team were also involved in the decisions about Mr A’s care at the end of his life. The Palliative Care team undertakes the same role as MacMillan nurses, and so there is no evidence the Trust failed to involve this service.
88. We recognise that this was a very difficult series of events for Miss L and her family and we hope that our work helps to reassure her that Mr A’s care appears to have been provided in line with the national guidelines.