Level of supervision
17. In the Trust’s response to Mrs D’s complaint about the supervision staff arranged for her husband, it said staff could not restrict patients removing their oxygen masks or getting out of bed. For example, to visit the bathroom.
18. However, given Mr D’s diagnosis of dementia and risk of falling, the Trust said staff should have considered an enhanced care assessment. This would have assessed whether he needed enhanced care, subject to staff availability.
19. The Trust also said nurses assessed he should not get out of bed unsupported. They would have encouraged him to use his call bell for assistance if he needed to get out of bed for any reason. It added staff gave him a falls clip as a precaution to remind him and alert staff if he was trying to get out of bed.
20. Until he died, the Trust said Mr D had been compliant with his oxygen treatment and staff were satisfied he knew and agreed he needed to keep his oxygen mask on.
21. We found staff did not take all the steps they should have regarding the level of supervision they arranged for Mr D. We explain our findings about this in paragraphs 23 to 36.
22. From paragraph 37, we explain why we did not see this links to the impact Mrs D described (in paragraph three), or it had any impact on what happened to her husband. From paragraph 41 we also explain why the Trust has taken the action we would expect to learn from what happened and improve.
23. Section 3.5 in the NMC Proficiencies say nurses must ‘accurately process all information gathered during the assessment process to identify needs for individualised nursing care and develop person-centred evidence-based plans for nursing interventions with agreed goals’.
24. In practice, our nurse said this meant the Trust’s staff needed to assess Mr D’s nursing needs when they admitted him to hospital. Based on his assessed needs, they needed to plan individualised nursing care to meet them.
25. From his care records, our nurse saw staff had an assessment like this in place. They added staff identified a need for this given his fall at home, and he appeared disoriented when they admitted him to hospital. Our nurse said staff then did a risk assessment which considered the factors they would expect staff to look for. This included assessing whether:
• he was over the age of 65 • he had confusion, agitation, or delirium • he had any neurological and/or cognitive impairment (like dementia) • he had any previous falls in the last 12 months • he had a fear of falling • he had difficulty with walking and/or his balance • he had any clinical, medical, or age-related condition increasing the risk of a fall.
26. Staff noted all the above factors applied to Mr D. On this basis, our nurse said the evidence in their assessment supported the conclusion staff made about him being at high risk of having a fall.
27. Our nurse said the most appropriate place for a patient at high risk of having a fall is not a side room, where staff placed Mr D. This is because it makes it more difficult for staff to see a patient relative to a traditional ward. However, because staff identified he was a high priority for isolation, our nurse said placing him in a side room was unavoidable.
28. We saw section 6.2.1 in the Infection Prevention Guidance explains, wherever possible, staff should place a patient with COVID-19 symptoms in a single room with ensuite facilities. This is to isolate them from other patients and minimise the spread of COVID-19.
29. Based on their assessments, to try and manage the high risk of Mr D falling, our nurse saw staff implemented a care plan to try and mitigate this risk. They said this included a plan about the level of monitoring he should have.
30. Based on his needs, staff planned to check on him hourly in his room. His records show staff performed these hourly observations.
31. Our nurse said this was in line with what they would expect to see based on the assessment staff did about his needs. We saw this is in line with the approach recommended by section 3.5 of the Nursing Proficiencies.
32. That said, our nurse saw a factor the Trust’s care plans referred to which staff needed to consider, and they did not do so.
33. As the Trust acknowledged, our nurse said staff should have considered doing an enhanced care assessment. They added the Trust’s falls care plan proforma contained a prompt to staff that they should consider such an assessment if a patient has a cognitive impairment impacting their ability to understand information and advice they provide.
34. In an enhanced care assessment staff consider any health conditions or behaviours which may mean a patient poses a risk of harm to themselves or others, and whether they require extra observation. If staff identify the patient needs enhanced care, they can ask additional staff to do extra observations, where staffing allows. This can include one-to-one monitoring.
35. Given Mr D’s diagnosis of dementia and staff recording his disorientation on admission, our nurse said staff should have done an enhanced care assessment.
36. Having considered this evidence and advice, we saw this was a possible need staff did not plan for further. This is not in line with section 3.5 of the NMC Proficiencies.
37. Our nurse considered the likely outcome regarding the level of supervision Mr D would have received had staff done an enhanced care assessment.
38. They said, while he had dementia and had been disoriented when staff admitted him to hospital, they saw entries in his records showing he could understand and retain information from staff. Therefore, subject to staff availability, they said the outcome was likely to be that staff decided to conduct intermittent observations on him.
39. Our nurse added staff already planned to do these observations as part of his care plan. These were the hourly observations we referred to in paragraph 30. Our nurse said this was the level of supervision they would expect to see in the circumstances.
40. Considering this information, we did not see the omission we found influenced the level of supervision Mr D received. It would have remained the same had staff done the additional assessment they should have, and we cannot see they should have planned greater supervision. Therefore, we did not find the assessment would have altered the course of events, or the failure to do it had any impact on what happened to Mr D.
41. Where we find care failings which did not lead to an impact or injustice, we can make recommendations to an organisation that it acts to prevent recurrence of these failings. This normally takes the form of asking the organisation to propose its own solutions to achieve this.
42. We did not see there is further action the Trust should take to improve on this matter. We saw it had taken actions like this already.
43. Our Principles for Remedy say, to prevent the same failings happening again, organisations can:
• revise policies and procedures • train or supervise their staff.
44. In its complaint process, the Trust confirmed the sister responsible for the team looking after Mr D discussed the omission we saw with their team. This was so they could take learning from what happened. This is a form of staff training facilitated by a supervisor.
45. As this is action in line with our Principles for Remedy, we did not see there is further work the Trust should do to learn lessons from what happened.
46. We recognise Mrs D is concerned about the supervision staff gave her husband and how this played a part in his death. We hope our findings help to bring her closure on this matter, and reassurance the Trust has taken action to improve. We appreciate she told us it is important to her that the Trust learns lessons from what happened.
Extension cord
47. In its complaint process, the Trust said staff did not attach an extension cord to Mr D’s oxygen mask. This was because he needed a high amount of oxygen, and walking to the toilet unsupervised meant such exertion would cause his oxygen levels to drop. Due to his risk of falling, using a cord so he could go to the bathroom himself increased the risk he might have a fall.
48. As he could mobilise to use a commode at his bedside with assistance from staff, the Trust said this was the approach staff took so he could use the toilet.
49. We found staff decided against attaching an extension cord to Mr D’s oxygen mask in line with guidelines.
50. As part of the risk assessment we referred to in paragraphs 25 and 26, staff recorded Mr D had difficulty walking and balancing. Staff also recorded he needed supervision to move.
51. Our nurse said extension cords are a trip hazard which increase the risk of a patient falling. They added the Patient Safety Guidance explains removing trip hazards is the most important modifiable risk factor staff can manage in minimising the risk of a fall.
52. Therefore, they said the Trust’s reasons for not using an extension cord were valid in trying to minimise this risk. Mr D was a patient at high risk of having a fall, and the extension cord would have increased this risk.
53. Having considered the evidence and advice, we saw staff decided against using an extension cord in line with the Patient Safety Guidance. As part of his nursing plan, to manage Mr D’s toileting and hygiene needs in view of his mobility and falls risk, staff planned bedside assistance to support him with this in his room. This is in line with the approach recommended by section 3.5 of the Nursing Proficiencies.
54. We know Mrs D considers an extension cord could have maintained her husband’s oxygen supply when he went to use the bathroom the day he died. On this basis, we recognise it will be difficult for her to reconcile our findings.
55. We hope we have clearly explained why staff acted in line with guidelines, and there were risks to her husband associated with using an extension cord.
IV fluids
56. In its complaint process, the Trust acknowledged Mr D’s medication charts show staff did not give him one litre of IV fluids which doctors had prescribed. Staff recorded they gave him his other fluid prescriptions. The Trust was not sure whether this was a record keeping error, and staff gave him these fluids but did not record doing so, or whether this was an omission.
57. Considering Mrs D’s complaint and what the Trust said in response, we identified conflict and uncertainty about what happened. That is, about whether staff gave Mr D all the IV fluids doctors prescribed him.
58. Noting this conflict and uncertainty, we reviewed the other available evidence to reach a view on the balance of probabilities about what happened. Based on that view, we considered whether what happened was in line with guidelines. Having been through this process, we found staff acted in line with guidelines, and they gave Mr D all the IV fluids doctors prescribed him.
59. Mr D’s care records show, during assessments and ward rounds on the morning of 1 January, doctors planned to slowly give him IV fluids. His IV fluid chart shows they planned one litre per day.
60. His IV fluid chart shows staff gave him fluid infusions of one litre on 1 and 2 January. We cannot see they recorded they gave him an infusion on 3 January. We appreciate the Trust says this may have been a record keeping error. We carefully reviewed other entries in his records to try and reconcile the uncertainty around this.
61. In a nursing note at 10.20pm on 1 January, the nurse recorded Mr D’s IV fluids were in progress but nearly finished. We consider this entry indicates the IV fluids staff noted they started in his IV fluid chart on 1 January were coming to an end.
62. In a nursing note entered at 10.36am on 2 January, the nurse recorded they had given Mr D all the medications he was due to have that morning. In a further note at 3.43pm, a nurse recorded he had finished his IV fluid infusion.
63. We consider this meant they were noting he finished the IV fluid infusion staff recorded they started on 2 January in his IV fluid chart, which their colleague appeared to have noted was in progress in the morning (at 10.36am).
64. At 4.58pm on 2 January, in a doctor’s progress note, the doctor recorded staff should continue Mr D’s IV fluids. A nursing note at 2am on 3 January noted the nurse inserted an IV cannula and had given him all his medications.
65. As a common use of cannulas include providing fluids, this indicated staff had started a further IV fluid infusion at this point. This followed the doctor’s instruction at 4.58pm on 2 January to continue with them. Our nurse reviewed Mr D’s records and reached the same conclusions about what his records indicated.
66. Therefore, having considered this advice and balanced all this evidence, we found staff gave Mr D his prescribed IV fluids in the 18-hour period before his death. That is, on 3 January. However, staff did not record they gave him these fluids in his IV fluid chart.
67. Section 5.7 in the NMC Proficiencies say nurses must manage artificial hydration using oral, enteral, and parenteral routes. In practice, our nurse said this meant the Trust’s nurses needed to give Mr D the IV fluids doctors prescribed him. Based on what we explained above, the evidence indicates nurses did this and acted in line with the NMC Proficiencies.
68. We recognise, understandably, her husband’s IV fluid charts gave Mrs D cause for concern regarding his IV fluids. We hope our findings help resolve her concerns about staff giving him the fluids doctors prescribed.
IV antibiotics
69. In its complaint process, the Trust said Mr D received all his antibiotics, except for one dose of IV antibiotics on the morning of 3 January. It added he received his next dose. It said staff recorded he declined his morning dose.
70. We found no failings in staff giving Mr D the IV antibiotics the Trust’s doctors prescribed in the 18-hour period before he died.
71. Section one of the Administration of Medicines Guidance says staff should administer medicines to a patient in accordance with a prescription.
72. Mr D’s prescription chart confirms doctors prescribed him IV co-amoxiclav. Doctors instructed staff to give him three daily doses of this antibiotic. That was, doses at 8am, 4pm, and 10pm. From the point doctors started this prescription, staff recorded they gave him these antibiotics up to 10pm on 2 January.
73. On the morning of 3 January, when staff tried to give him his first daily dose, they recorded he refused to have his antibiotics.
74. When administering any medicine, section 15 of the Administration of Medicines Guidance says staff must have the consent of the patient to give them the medication. If a patient refuses their medication, section 17.2 says staff should tell the prescriber of the medicine. This is so they can take appropriate action as necessary.
75. Our nurse said staff acted in line with this guidance by not giving Mr D his antibiotics when he refused them on the morning of 3 January.
76. In later entries, we saw the consultant overseeing his care noted they spoke to him around 1pm about his diagnosis and the need for him to take his antibiotics. This shows nurses alerted the consultant in charge of managing his prescriptions. The consultant recorded Mr D confirmed he understood he needed to take all his medications.
77. Following this conversation, his prescription charts then show staff gave him his next dose of IV antibiotics at 4pm. They also recorded the missed dose at 8am, and, by writing a four on the chart, this was the time they recommenced his co-amoxiclav prescription.
78. Our nurse said this was what they would expect to see. Sadly, Mr D died before staff were due to give him his next dose at 10pm.
79. Considering this evidence and advice, we saw staff respected his right to refuse medication when they sought consent to give him his IV antibiotics. In line with the Administration of Medicines Guidance, staff told the consultant responsible for prescribing his medicines. This clinician then acted through discussing his diagnosis to convince Mr D to recommence the antibiotics necessary to treat him.
80. We do not underestimate how difficult it must be for Mrs D to know her husband missed a dose of his antibiotics on the day he died.
81. We hope we have clearly explained our findings on this matter. We hope they help to give her some reassurance about what happened, and about staff escalating concerns they had about Mr D refusing his antibiotics.
The type and amount of oxygen staff gave Mr D
82. In her complaint to us, Mrs D told us the Trust’s Oxygen Guidelines say, after starting a patient on (non-humidified) oxygen, staff should switch to humidified oxygen after 24 hours. She complained staff did not do this in her husband’s care.
83. She added the Trust’s Oxygen Guidelines say staff should provide enough oxygen to achieve target oxygen saturation levels of 94% to 98% in acutely unwell patients. The exception is for patients at risk of type two respiratory failure, where the target is 88% to 92%. She said the guidelines referred to chronic obstructive pulmonary disease (COPD) as a risk factor for this.
84. She said her husband did not have COPD. Therefore, she complained it was wrong for staff to aim for the lower target. Staff should have provided enough oxygen, through therapies like continuous positive airway pressure (CPAP) if necessary, to attain at least 94%.
85. She added her husband’s records showed his oxygen saturation levels dropped to 85% at 12.44pm on 3 January. She also said his NEWS showed deterioration in his condition, and staff recorded scores of seven or above during his admission. Despite this, staff did nothing to escalate his oxygen treatment.
86. In its complaint process, the Trust said staff firstly needed to give Mr D the amount of oxygen he needed to maintain the oxygen saturation level target staff set. It added staff gave him oxygen through a venturi face mask (a type of oxygen mask) to do this.
87. However, after 24hours, staff should have considered whether to switch to giving him humidified oxygen. Staff should have documented whether they decided to make this change.
88. The Trust added staff saw Mr D’s oxygen saturation levels remained between 92% and 88% on 3 January while on the oxygen staff gave him. It said he had risk factors for retaining carbon dioxide, known as type two respiratory failure. Therefore, his oxygen levels, and the oxygen staff provided to maintain this, aligned with the Trust’s Oxygen Guidelines.
89. To clarify some terms explained above, CPAP is a therapy where a machine pumps air into a mask a patient wears over their mouth and/or nose. The continuous delivery of air helps to keep their airway open.
90. NEWS assess a patient’s breathing rate, oxygen saturation level, blood pressure, heart rate, level of consciousness, and temperature. Staff give each parameter a score between zero and three. A score of zero means the parameter is normal. Higher scores indicate the patient is more unwell.
91. Staff add up scores for each parameter to give a total score. They should add two to this score if they need to give a patient supplemental oxygen. A higher overall score means the patient is more unwell and at higher risk of deterioration. The RCOP Guidance says NEWS of one to four is a low score. NEWS of seven or more is a high score.
92. We found no failing in staff not giving Mr D humidified oxygen. We explain our findings on this in paragraphs 94 to 98. We found staff did not act in line with guidelines regarding the amount of oxygen they gave Mr D from 3 January. We explain our findings on this in paragraphs 99 to 111.
93. From paragraph 112, we explain why we did not see the omissions in how much oxygen staff gave him link to the impact Mrs D described (in paragraph two and three), or this had any impact on what happened to her husband. That said, from paragraph 117, we explain why there is action the Trust should take to improve in view of the omissions we found.
94. Regarding humidified oxygen, the Trust’s Oxygen Guidelines say staff should use it when they have been giving a patient oxygen for 24 hours. This is important in patients who report upper airway discomfort because they feel their airway is dry.
95. However, our physician said, had staff considered humidified oxygen, national guidelines do not indicate they should have given Mr D humidified oxygen. The Respiratory Care Guidance and NICE Guideline 191 do not refer to using humidified oxygen in the care of COVID-19 patients. Our physician said the BTS Oxygen Guidance applies to all patients receiving oxygen in hospital.
96. Section 10.6 in the BTS Guidance says humidified oxygen may reduce the sensation of dryness in the upper airway which oxygen can cause. However, in non-intubated patients, there is little evidence humidified oxygen has any benefit. In the absence of an artificial airway, staff should decide on using humidified oxygen on an individual basis, but this practice is not evidence-based.
97. We did not see staff recorded Mr D complained of dryness in his airway. Our physician said staff did not intubate him. Therefore, they did not see indications for staff giving him humidified oxygen.
98. Having considered all the above, while staff should have considered humidified oxygen for Mr D, they did not breach national guidelines in not providing it. Given we have expert advice about what guidelines apply, and the national ones we refer to in paragraph 95 are more recent than the Trust’s Oxygen Guidelines, we are satisfied the national guidelines we highlighted are more relevant here.
99. Regarding the amount of oxygen, the Respiratory Care Guidance recommends staff should aim to keep a patient’s oxygen saturation levels at 92% to 96% through the oxygen they provide. If staff achieve this through using an oxygen mask like a venturi mask, they should continue to provide the oxygen and keep monitoring the patient.
100. If the patient is at risk of hypercapnic respiratory failure staff should aim for a lower target oxygen saturation level of 88% to 92%. Hypercapnic respiratory failure, or type two respiratory failure, occurs when a patient has too much carbon dioxide in their blood.
101. If staff cannot keep a patient’s oxygen levels on target, the Respiratory Care Guidance recommends escalating their care. This can include trialling therapies like CPAP. NICE Guideline 191 also recommends CPAP in COVID-19 patients who have hypoxaemia, and they are not responding to supplemental oxygen. NICE Guideline 191 does not set a lower limit regarding a patient’s oxygen saturation levels on when staff should start CPAP.
102. Our physician said Mr D was not at risk of hypercapnic respiratory failure. His blood tests showed low levels of carbon dioxide.
103. Therefore, we saw the guidelines we referred to above confirm staff should have given Mr D enough oxygen to keep his oxygen saturation levels between 92% and 96%.
104. The observations staff recorded in his records show he maintained these oxygen levels throughout 1 January through the oxygen staff gave him using a venturi face mask. At the end of the day, nurses noted this level fell to 88%.
105. In line with the Respiratory Care Guidance, they escalated his care and approached a doctor. One of the Trust’s doctors asked nurses to increase the flow of oxygen through his mask from 40% to 60% and check how he responded. His oxygen saturation levels increased to 92% or above. Therefore, staff continued to give him oxygen through his mask at a 60% flow rate and keep monitoring him.
106. The observations staff documented show Mr D continued to maintain these oxygen saturation levels until the morning of 3 January. In the ward round at 12.24pm, doctors noted his oxygen saturation levels had fallen to 85%.
107. Doctors decided to alter his oxygen saturation target to 85% to 90%. If his oxygen levels fell below 85%, they advised staff they should start him on CPAP therapy. The doctor did not document any reason for changing the target.
108. This is not in line with the guidelines we have referred to. The oxygen saturation target was below the level of 92% these recommend.
109. As Mr D’s oxygen levels had dropped below this threshold, our physician said staff should have increased his oxygen treatment. If providing a higher level of oxygen did not increase his oxygen levels to 92%, they added staff should have considered CPAP therapy.
110. Instead, we saw staff continued to give him oxygen through his venturi mask at a 60% flow rate. Staff did not change this treatment before he died.
111. Having considered the evidence and advice, we saw staff gave Mr D the amount of oxygen they should have to maintain high enough oxygen levels until late in the morning on 3 January. After that they did not act in line with guidelines by increasing his oxygen treatment. This included missing the opportunity to start CPAP therapy at that time.
112. We did not find these omissions link to the impact Mrs D describes, and staff lost the chance to improve Mr D’s condition and oxygen levels. We did not see they link to his death.
113. After the ward round on 3 January, his oxygen saturation levels improved with the existing treatment staff had in place. By 4.37pm, his records show his oxygen level increased to 88%. Staff also noted his levels were 88% when they last saw him alive around ten minutes before they found him in the bathroom that evening.
114. While this was lower than the 92% target staff should have been aiming for, our physician said this was not a significant difference. They added this was not the reason he died. He died because he went to the bathroom without his oxygen supply.
115. Considering this evidence and advice, it shows Mr D’s condition and oxygen levels improved despite the omissions we saw following the 3 January ward round.
116. We also note CPAP therapy needs a patient to wear a mask connected to an oxygen supply. Therefore, whether he received more oxygen through the venturi mask he had, or oxygen through CPAP therapy, this would not have made a difference to him being cut off from the oxygen supply maintaining his oxygen levels. As our physician identified, these levels dropped very quickly when he was off oxygen, and this led to his death.
117. As we explained in paragraph 41, even where we identify no impact linked to a failing in care, we may recommend an organisation takes action to prevent recurrence of any failings we see.
118. In its complaint process, the Trust did not acknowledge the omissions in Mr D’s care we saw on this matter. It also has not yet taken action to prevent them happening again.
119. For this reason, we are asking the Trust to take action like this. We explain our recommendations on this in more detail in the recommendations section at the end of our report.
120. We recognise Mrs D reviewed her husband’s medical records and the Trust’s Oxygen Guidelines. Based on what she saw, we recognise why she raised concerns about the oxygen staff provided.
121. We hope we have clearly explained our findings, and they help provide Mrs D some degree of closure about the impact of the Trust’s mistakes. We also hope the recommendations we explain later assure her about the action we are asking the Trust to take to learn from what happened and improve.
Updates about deterioration and end of life
122. In Mrs D’s complaint to the Trust, she said her family spoke to her husband in a video call on 2 January. He was alert at this point.
123. She said her family tried calling staff on 3 January to check on his welfare, and staff did not answer these calls. At the time, her family believed he was stable, and staff would inform them if he deteriorated. Later in the evening, she said staff called to tell her family he had died. She said this came as a shock because her family did not expect him to die without warning.
124. In its complaint process, the Trust acknowledged staff contacted Mrs D’s family only after her husband died. That said, the Trust added his observations remained steady throughout the day. There was no clinical indication he was likely to deteriorate suddenly and die.
125. We found no failings in staff notifying Mrs D’s family about her husband’s condition deteriorating or in respect to him approaching the end of his life.
126. Our physician said there is no guideline about exactly when and how often staff should update a patient’s family about their condition. Section 33 in Good Medical Practice says staff must be considerate to those close to a patient and be sensitive and responsive in giving them information and support.
127. To be responsive, we consider staff should inform a patient’s family about significant changes in their condition. This would include telling relatives if a patient is approaching the end of their life.
128. As Mrs D told us, we saw her family spoke to Mr D the evening of 2 January. The entry about this in his records shows, when staff helped set up the video call, they also updated his family about his condition.
129. Our physician said he was seriously ill with COVID-19. That said, the evidence they saw on his condition after that point did not indicate he was approaching the end of his life. They did not consider it would have been appropriate staff told his family he was.
130. As our physician said in paragraph 114, the fall in his oxygen levels on 3 January was not a significant difference relative to the oxygen saturation levels staff should have been aiming for. They also said staff could not have predicted Mr D leaving his bed without his oxygen, his collapse in the bathroom, and how suddenly he died because of this.
131. Having reviewed this evidence and advice, we found the unpredictable and sudden way Mr D died meant it was not possible for staff to inform his family about deterioration in his condition and he was likely to die so soon. Therefore, we did not see staff failed to give his family the kind of information Good Medical Practice recommends.
132. We can only begin to imagine how difficult it was for Mrs D’s family to hear how her husband died in a telephone call from staff. We recognise she did not expect him to die based on her understanding of his condition at the time, and she was not prepared for this event.
133. We hope we have clearly explained our findings on this matter, and all the other issues Mrs D has complained about. We hope our explanations on these issues assure her we only reached our conclusions following careful consideration of the evidence.