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.
17. If there are indications things did go wrong then we consider what impact they had and what the organisation responsible has done to put things right.
18. We have done this and not found any indications things went wrong with Mrs E’s stroke diagnosis or NG tube placement. We also consider the Trust has done enough to put right the impact associated with the potentially missed COVID-19 booster.
Stroke diagnosis in ED
19. Miss L complains the Trust did not diagnose her aunty had a stroke as soon as it could have done.
20. The Trust explained it did not immediately suspect a stroke when Mrs E arrived in the ED on 20 August because she did not display any of the telltale symptoms. The three most common signs of a stroke are: • facial weakness, like problems smiling or a drooping eye or mouth.
• difficulty raising both arms and keeping them there • slurred speech and difficulty understanding information.
21. NICE stroke guidelines explain a doctor should assess someone who had a suspected stroke by examining their face and arm weakness, as well as their speech. This is known as the FAST tool.
22. Alternatively, they could use the Recognition of Stroke in the Emergency Room (ROSIER) Scale. This assesses the possibility of a stroke by considering symptoms such: • loss of consciousness • seizure • asymmetrical facial weakness • asymmetrical arm weakness • asymmetrical leg weakness • speech disturbance • sight defects
23. Crucially, FAST and ROSIER are only recommend when the patient has a sudden onset of neurological symptoms and a stroke is a possibility.
24. Neurological symptoms of a stroke include: • headache • dizziness • confusion and memory loss • a severe headache • nausea or vomiting
25. Our ED adviser explained Mrs E did not show signs of having a stroke when she attended ED. Instead, her presentation indicated her ankle injury was the acute problem. Our adviser added even if the ED doctor had assessed Mrs E with FAST or ROSIER it is unlikely that her symptoms in ED would have led to the diagnosis of a stroke sooner.
26. With this in mind, we consider staff in ED acted in line with guidelines when they did not investigate the possibility Mrs C had a stroke.
27. We recognise the worry Miss L has told us about and understand the distress she has experienced. We hope she finds it reassuring to learn ED doctors did not miss signs Mrs E had a stroke.
Stroke diagnosis on the ward
28. The Trust explained a consultant visited Mrs E on 21 August and identified her left-sided weakness and facial droop. The consultant arranged a CT scan, and it showed no indications of a recent stroke. However, Mrs E’s symptoms continued to the following day so the consultant arranged an MRI scan. This scan identified she had experienced a stroke.
29. NICE stroke guidelines explain patients should have a CT scan as soon as possible, and within 24hours, of the suspected stroke. If this scan excludes a bleed within the brain (intracerebral haemorrhage) then the doctor should give the patient 300mg of aspirin. The aspirin helps stop another stroke happening.
30. RCP guidelines add if there is still uncertainty about whether someone had a stroke then doctors should perform an MRI scan.
31. A CT scan uses X-rays to produce images of the inside of the body. They are quick and useful for identifying emergency problems, like if a stroke is still bleeding. Alternatively, MRI scans produce more detailed images but take longer to do. This detail means it is easier to see subtle differences and arrive at a diagnosis.
32. Our geriatrician adviser explained when the consultant saw Mrs E in the morning of 21 August they identified she had symptoms of a suspected stroke. The consultant asked for a CT scan which happened approximately two hours later.
33. We consider this CT scan was in line with guidance and happened within the timeframe NICE recommends.
34. The CT scan did not identify a stroke but did exclude an intracerebral haemorrhage. The consultant prescribed and administered 300mg of aspirin at 6pm. We consider this was also within the timeframe NICE recommends.
35. The consultant asked for an MRI scan of Mrs E’s head on the following day. The guidance only recommends this if there is uncertainty around the diagnosis. Whilst there was no uncertainty around the diagnosis Mrs E had received in this instance, her persistently painful lower leg may have been causing some concern.
36. We consider staff on the ward acted in line with guidance when they initially requested a CT scan to investigate the possibility Mrs E had a stroke. It was also in line with guidance to follow this up with an MRI scan when there were concerns.
37. Whilst our decision does not diminish the sad events Miss L experienced we hope she finds it reassuring that doctors on the ward took appropriate steps in line with guidance to diagnose and treat Mrs E.
NG tube placement
38. Miss L complains the NG tube staff gave her aunty on 30 August was not placed properly, and believes it worsened Mrs E’s condition.
39. The Trust explained staff suspected problems with Mrs E’s swallow so made a referral to the Speech and Language Therapy Team (SALT). This team is responsible for supporting stroke patients with their communication and swallowing difficulties.
40. SALT reviewed Mrs E at 3.30pm on the 23 August 2022 and planned to continue providing regular mouthcare but stopped her from eating. This was to reduce the risk of her choking. An NG tube was noted as a possibility should the situation have not improved as it allows food and liquid to be given to the patient safely.
41. Thankfully Mrs E’s swallowing did improve and she was able to tolerate a diet of purees and liquids. However, by 28 August her swallowing had worsened again.
42. SALT reviewed her on 30 August and made further adjustments to her diet. Despite these changes they decided it was not safe to let Mrs E eat due to her poor swallowing. This is referred to as being ‘nil by mouth’. Mrs E agreed to have an NG tube and it was placed that day.
43. NICE NG tube guidelines set out what should happen if someone has difficulty swallowing (dysphagia) after a stroke. It explains they should receive a specialist assessment of their swallowing, and be considered for an NG tube within 24-hours.
44. NICE NG tube guidelines also set out how NG tubes should be managed when in place. They explain placement should be confirmed by using the tube to extract some fluid and testing its pH. If the fluid is acidic then it is correctly placed in the stomach. However, if the test is inconclusive then an X-ray should be used to confirm placement instead.
45. Our geriatrician adviser explained Mrs E’s swallow was closely monitored throughout her admission. Nursing staff raised further concerns about it on 28 August and decided she should be nil by mouth again. Unfortunately, changes to her diet did not resolve the problem so she agreed to have an NG tube on 30 August.
46. Our adviser added when the NG tube was put in place, doctors took fluid from the tube to check it was positioned correctly. No fluid came out, so staff performed a chest X-ray. This confirmed her NG tube was placed in her stomach as intended.
47. We consider Mrs E had the right clinicians overseeing her swallow. They made an appropriate decision to give her an NG tube and checked to ensure it was in the correct place. These actions are recommended by the guidance.
48. We understand Miss L believed the NG tube was placed incorrectly and caused her aunty problems. We acknowledge the worry this caused and hope our explanations of events is reassuring to her.
COVID-19 jab
49. Miss L complains the Trust did not give her aunty a COVID-19 vaccine booster jab whilst she was a hospital inpatient. Miss L says this meant her aunty was more vulnerable to becoming ill with COVID-19. Mrs E sadly caught COVID-19 in hospital and tested positive on 5 October. She sadly died 17-days later.
50. The Trust’s policy was that an inpatient is eligible for a vaccine after being in hospital for more than 10-days, like Mrs E. Once they had been identified, the hospital’s trained vaccinator could give the COVID-19 jab. Alternatively, a member of the cross-Trust vaccination team could visit.
51. The Trust’s complaint response explained it only started to receive vaccines at the end of September, but these had not made it to the hospital where Mrs E was. At this point, that hospital’s trained vaccinator was not at work and only returned after Mrs E had tested positive.
52. The Trust added ward staff did not refer Mrs E to the cross-Trust vaccination team and ask if they could visit the hospital prior to Mrs E testing positive. The ward manager explained they were unaware the cross-Trust vaccination team existed.
53. It appears the nursing team failed to refer Mrs E to the cross-Trust vaccination team in line with its policy. We have therefore considered the possible impact this had on Mrs E.
54. Miss L says her aunty was at a higher risk of catching COVID-19 because she did not have the booster. Whilst a missed booster may have increased the risk of catching COVID-19, we must balance this against the other facts of what happened.
55. Specifically, vaccines arrived at the Trust at the end of September. Therefore, there is no guarantee the boosters arrived in time or in sufficient quantities for Mrs E to be vaccinated. Additionally, there is no guarantee the cross-Trust vaccination team would have been able to visit Mrs E before she tested positive for COVID-19 on 5 October.
56. Furthermore, people can still catch COVID-19 and become seriously unwell when they are fully vaccinated. This means even if Mrs E had been vaccinated it is entirely possible she would still have become ill with COVID-19 and experienced the same health problems.
57. With this in mind, it appears Mrs E missed a slim opportunity to be considered for her booster. We cannot say if this would have meant Mrs E got the booster, or whether this affected her health. However, we acknowledge the worry and distress this missed referral caused for Miss L.
58. We have therefore considered if the Trust has done enough to put right the worry and distress Miss L experienced due to the potential missed opportunity.
59. To decide if the Trust has done enough to put things right, we have referred to our NHS Complaint Standards. These say organisations should acknowledge when they get things wrong and apologise. They should also make changes to ensure the same problems do not happen again. In some circumstances they should also pay compensation.
60. In its complaint response, the Trust gave a full explanation of its actions and accepted things should have gone differently. It also sincerely apologised to Miss L for what happened.
61. Furthermore, the Trust’s response explained the lead nurse spoke to all staff and shared the correct procedure for referring eligible patients for their COVID-19 vaccination. They have also produced posters for the wards to ensure the same problem does not happen again in the future.
62. We acknowledge Miss L would like financial compensation to put this issue right. In this instance we have decided compensation is not necessary. This is because we are satisfied the Trust has appropriately acknowledged things went wrong, apologised for them and taken steps to stop them happening again. We consider this sufficiently resolves this issue.
63. Whilst we cannot say things would have happened differently for Mrs E, we understand how much this issue means to Miss L. We understand the worry she has experienced and how this has made her sad experience worse.