Emergency department
23. Mr O says that during Mr A’s attendances at the ED on 29 April and 1 May 2021 the Trust discharged him without a diagnosis or treatment.
29 April 2021
24. Mr A attended the ED on 29 April as he had worsening chest pain. A Trust nurse practitioner reviewed him.
25. The NMC’s Standard for Specialist Education and Practice says nurses should ‘assess health, health related and nursing needs of patients or clients, their families and other carers by identifying and initiating appropriate steps for effective care for individuals and groups’.
26. The records show the nurse practitioner reviewed him and completed airway, breathing and circulation assessments (ABC). These tests help a clinician identify if there are any features of a life-threatening condition. These results were normal.
27. As these results were normal the Trust’s nurse practitioner arranged for Mr A to have blood tests, an electrocardiogram (ECG – to check heart rhythm), and an X-ray. The nurse was acting in line with the NMC guidance above. They assessed Mr A’s condition and arranged further tests to help diagnose his condition. Our emergency medicine adviser told us that the tests ordered were to rule out a cardiac issue, and the results of the tests were normal.
28. These results were normal. The Trust’s nurse discharged Mr A the same day with a diagnosis of atypical chest pain and musculoskeletal pain.
1 May 2021
29. Mr A attended the ED again on 1 May 2021 as, since on 29 April, his mobility had decreased.
30. GMC guidelines say doctors should ‘adequately assess the patient’s conditions, taking account of their history (including the symptoms […])’ and ‘where necessary, examine the patient’. Doctors should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’ and ‘refer a patient to another practitioner when this serves the patient’s needs’.
31. The records show the Trust’s doctor reviewed Mr A. They did assessments to measure his vital signs. They documented his airways were open with no obstruction, his breathing was clear, a respiratory rate of 15 and oxygen level of 96%, a pulse rate of 74, temperature of 36.1oC, and blood pressure of 78/40. His national early warning score (NEWS) was 4. NEWS is a tool to assess a patient’s condition by scoring physiological observations. A score of 4 means a person has a low clinical risk of deterioration.
32. The Trust’s doctor ordered blood tests, ECG, and lower limb assessments. The Trust’s doctor completed lower limb assessments which were normal and noted Mr A had no sensory or coordination problems. Our emergency medicine adviser told us the tests the Trust performed were to rule out any neurological problems.
33. The Trust gave a working diagnosis to Mr A of ‘elderly man with mobility issues’. The Trust doctor arranged for Mr A to be assessed further via an admission at a community hospital for mobility aid.
34. We find the Trust’s doctor assessed Mr A in line with GMC guidance. They discussed Mr A’s history and arranged for him to have investigations. The Trust’s doctor diagnosed Mr A as an elderly patient with mobility issues following these investigations. The Trust doctor arranged for further treatment for Mr A and arranged for him to be admitted to a community hospital for mobility aid.
35. Overall, during Mr A’s presentations at the ED on 29 April and 1 May 2021, the Trust assessed, diagnosed and treated Mr A. Our view is that on both presentations it acted in line with the NMC and GMC guidance above.
36. We understand why Mr O has concerns about his father-in-law being discharged given what went on to happen. We hope our explanations above provide some comfort that what should have happened did happen in Mr A’s emergency department care on 29 April and 1 May 2021.
37. We therefore do not uphold this part of the complaint.
Pressure sores
38. Mr O says his father-in-law developed pressure sores whilst under the care of the Trust from 6 May 2021. He says the Trust did not prevent or treat them.
39. The Trust said it used the Waterlow tool to assess Mr A’s risk of developing pressure sores during his admission.
40. The Waterlow score is a tool to assess the risk of individual patients developing pressure sores. It assesses risk factors that contribute to the development of pressure ulcers. These risk factors are age and gender, body mass index (BMI), level of continence, skin condition (healthy or broken), appetite and level of mobility (fully mobile to bed-bound). It also assesses individual risk factors such as medication, surgery and trauma. The patient is then allocated a score for each of the above criteria. The total score, in conjunction with the nursing staff's clinical expertise, places the patient into one of three pressure sore risk categories:
• a score of 10-14 indicates ‘at-risk’ • a score of 15-19 indicates ‘high risk’ • a score of 20 and above indicates ‘very high risk’.
41. Mr A’s GP referred him to the Trust on 6 May 2021. The Trust’s nurse assessed his risk for developing pressure sores and said his mobility was ‘very poor’. After assessing Mr A’s risks factors, they found he was at risk of developing pressure sores.
42. On 8 May the Trust documented Mr A did not any have feeling in his legs, and needed assistance eating and drinking. The Trust also started to give him intravenous (IV) steroids the same day.
43. NICE guidance CG179 says Trusts should ‘Reassess pressure ulcer risk if there is a change in clinical status (for example, after surgery, on worsening of an underlying condition or with a change in mobility)’.
44. Our nursing adviser said the changes in Mr A’s condition described in paragraph REF _Ref184198713 \r \h 42 constituted a change in clinical status. They said these changes meant Mr A was now likely at ‘very high risk’ of developing pressure sores.
45. We find the Trust did not reassess Mr A’s pressure sore risk on 8 May even though his clinical condition had changed. It failed to act in line with NICE guidance here.
46. Mr A would have likely scored very high risk on his Waterlow tool score. NICE guidance says that for patients at very high risk of pressure sores the following measures should be put in place:
• regular positional changes every four hours • an off-loading of pressure from the heels • a pressure redistributing mattress.
47. The records show the Trust changed Mr A’s position every four hours between 9 and 11 May. From what we saw the Trust did not complete fourhourly positional changes before 9 May or after 12 May. It only did positional changes at 12 noon and 11.15pm on 12 May. On 13 and 14 May the Trust performed one positional change each day. It did two on 15 May.
48. The Trust did not complete a new pressure sore assessment on 8 May. If it had done so we think it is likely it would have raised his pressure sore risk to very high risk. Not doing so meant it did not recognise the new risks or put any of the above preventative measures outlined in paragraph 46 in place. This was a failing.
49. A Trust nurse did a further review of Mr A’s pressure areas on 9 and 10 May and noted he had a sore red area on his left heel and ordered a nimbus mattress. The Trust’s nurse reviewed him again later that day and noted his heels and bum were slightly red and after a discussion with ‘colleagues’ decided to not move him to a nimbus mattress ‘due to MRI results’. Mr A had had an MRI scan that day. The note gives no further detail about what in particular in the MRI scan results would have prevented use of a nimbus mattress. The Trust also took no other action to reduce the pressure on Mr A’s heels, such as elevating them.
50. NMC guidance says nurses should ‘work with colleagues to preserve the safety of those receiving care […], share information to identify and reduce risk [and] ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’.
51. The records show the Trust did not give Mr A a nimbus mattress after the nurse’s ‘discussion with colleagues’. The records are silent on which members of staff were involved in this discussion. It is clear from the evidence we have seen the nurse was unsure, and that this decision was outside of their remit of competence hence the discussion with others. But there is no evidence the nurse escalated this to a more senior nurse or a doctor. This was not in line with NMC guidance and was a failing.
52. We considered the tool used by the Trust to assess Mr A’s pressure sore risk during his admission. The Trust said in its complaint response that it used the Waterlow tool.
53. NICE guidance says consider using a validated scale to support clinical judgement (for example the Waterlow score). We looked at the nursing records and pressure sore reviews and we have not seen any evidence within Mr A’s medical records that the Trust used the Waterlow score tool during his admission. We find this was also a failing.
54. We will move on to cover impact later in this report.
Pain management
55. Mr O says that during his fatherinlaw’s admission the Trust did not treat his pain.
56. NMC guidance says nurses should ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’. It also says they should ‘make a timely referral to another practitioner when any action, care or treatment is required’.
57. The records show the Trust prescribed as required paracetamol and oromorph (opioid pain medication) during his admission. The records show Mr A complained only twice about pain, once on 2 May and once on 3 May.
58. Both times, the Trust gave him pain relief, and nurses raised this with the medical team. This was in line with NMC guidance. The nurses found he was in pain, treated it and correctly escalated it to the medical team. These interventions reduced his pain. There were no other instances noted in the records of Mr A saying he was in pain.
59. We can understand why Mr O has questioned if the Trust adequately managed his fatherinlaw’s pain during his admission. We hope our explanations help reassure him that it did. We therefore do not uphold this part of Mr O’s complaint.
Referral
60. Mr O says the Trust did not refer his fatherinlaw to the right specialism on 6 May. He says the Trust incorrectly referred his father to spinal surgery instead of neurosurgery/neurology.
61. GMC guidance says doctors should ‘refer a patient to another suitably qualified practitioner when this serves their needs’. NICE NG127 guidance says ‘Refer immediately adults with rapidly (within 4 weeks) progressive symmetrical limb weakness for neurological assessment and assessment of bulbar and respiratory function’.
62. The records show a doctor reviewed Mr A on 6 May 2021 and noted ‘rapid decline -mobility and legs weak’. The doctor referred Mr A for an MRI scan but did not refer him for a neurology assessment as per the NICE guidance above. We find this was a failing.
63. A Trust doctor reviewed Mr A on 7 May and recommended a ‘neurology’ opinion. This was in line with the NICE guidance. A doctor made a referral to neurosurgery on 7 May, but when the referral was triaged, they asked if Mr A had suffered a fall. The doctor did not appear to mention the neurological symptoms Mr A was having and this therefore resulted in a referral to orthopaedics.
64. The Trust’s orthopaedic team reviewed this referral the same day, and noted that Mr A should be managed by neurosurgery. We find the Trust should have been aware of the reasons it was making a referral, and that Mr A would not meet the criteria for a referral to orthopaedics, and that he should have been under the care of neurosurgery.
65. Overall, the Trust did not follow GMC or NICE guidance when referring Mr A to neurosurgery. Mr A needed to be referred to neurosurgery on 6 May and due to communication failings, the doctor ended up changing the referral from neurosurgery to orthopaedics. This caused a 48-hour avoidable delay in Mr A being under neurosurgery. We find this was a failing.
66. We will move onto the impact later in our report.
Stroke
67. Mr O says the Trust did not diagnose his father with a spinal stroke.
68. We want to recognise the difficulties the Trust had in diagnosing Mr A. It relied upon an external neurosurgery team who were not located at the Trust he was at. The Trust had multiple working diagnoses which included transverse myelitis, spinal stroke and an inflammatory cause. These conditions have very similar symptoms.
69. The national clinical guideline for stroke says ‘people with an acute neurological presentation suspected to be a stroke should be admitted directly to a hyperacute stroke unit that cares predominantly for stroke patients and have access to a designated thrombectomy centre for consideration of mechanical thrombectomy’. NICE NG128 guidance on strokes says ‘Refer immediately people who have had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms.’
70. The records show the Trust first suspected Mr A was having a spinal stroke on 8 May when the neurology team said it could be a stroke. Our neurology adviser told us at this point Mr A needed to be referred to a stroke unit for an assessment within 24 hours as per the guidance set out above.
71. The Trust’s stroke consultant did not review Mr A until 12 May and documented the onset of symptoms was ‘2-3 days ago’. The Trust’s stroke consultant did not think Mr A had had a stroke, but did offer a transfer to a stroke unit if neurology still thought it was a stroke.
72. While the stroke consultant did not think Mr A had had a stroke, it appears they had not fully ruled it out at this stage. Our neurology adviser told us that the consultant did not appear to be sure, and Mr A should have been treated and moved to a stroke unit until it was fully ruled out.
73. Overall, the Trust still ‘suspected’ a stroke and therefore should have referred Mr A to a specialist stroke unit until a stroke had been ruled out. The Trust did not refer Mr A to a stroke unit either on 8 May or following the further review on 12 May. We find that was not in line with the guidance above and was a failing.
74. Mr A was later diagnosed with a spinal stroke on 17 May at another Trust, this was also a secondary cause of death on Mr A’s death certificate.
75. The Trust missed opportunities to diagnose Mr A with a spinal stroke or rule it out sooner, and when it did review him, it failed to take steps to move him to a stroke unit or fully rule it out.
76. We will cover the impact later in our report.
Impact
77. In this section we will consider the above failings and the impact they had on Mr A and his family.
78. Our view is that the Trust did not manage Mr A’s pressure sores in line with NICE guidance or its own policy. The Trust did not recognise that Mr A was at ‘very high risk’ of developing pressure sores on 8 May.
79. As the Trust did not recognise Mr A was at very high risk, this led to it not putting in place preventative measures. The Trust did not move Mr A to a nimbus mattress until 12 May. Nor did it complete positional changes every four hours.
80. We asked our nursing adviser if the Trust could have moved Mr A to a nimbus mattress sooner. Our nursing adviser told us Mr A’s treatment or condition did not change between 9 and 12 May, and therefore it is likely the Trust could have used the mattress on 9 May. We have seen nothing to explain why the Trust could not provide a nimbus mattress before then given his condition did not change. Overall, this was a three-day avoidable delay.
81. We also found the Trust noted Mr A began to develop pressure sore damage on 10 May and his heels were red. The Trust did not elevate his heels until 11 May. Our nursing adviser told us the Trust elevated Mr A’s heels a day after the damage had been found.
82. National Patient Safety Agency says ‘unavoidable’ means that the individual developed a pressure ulcer despite all preventative measures having been completed.
83. We asked our nursing adviser if Mr A’s pressure sores were avoidable. Our adviser told us Mr A’s pressure damage could have been prevented had all of the steps in NICE guidance been taken.
84. Mr O told us he thinks the Trust’s poor pressure sore care caused them to become worse and denied him a dignified death. We can understand why Mr O thinks this, and we have found that Mr A’s pressure sores were likely avoidable. Mr A should not have had pressure sores when he died. It is likely the Trust’s failings prevented Mr A having as dignified a death as possible given the deterioration in his pressure sores.
85. We understand the Trust reflected on this part of the complaint in its complaint response. It said:
‘On reflection It would have been prudent to reassess Mr A’s risk of developing pressure sores on 9 May 2021 when he was commenced on IV steroids for 5 days for suspected myelitis as the addition of high dose steroids and the effect his neurological deficit (paraplegia) had on his daily activities would have increased his pressure sore risk to ‘very high risk’ (score 21). This may have resulted in the earlier application of a nimbus mattress, i.e. 9 May instead of 12 May 2021. That said, staff did have significant concerns about the appropriateness of a nimbus mattress due to the inflating and deflating air cells and the potential adverse effect on spinal cord compression’.
86. Our NHS Complaint Standards say ‘organisations should welcome complaints in a positive way and make sure people are being listened to and treated with empathy, courtesy and respect’.
87. The Trust has reflected on this situation, and it was right to do that, but it has not taken any specific actions other than reflecting and has not apologised. This was not in keeping with the NHS complaint standards which say the Trust should be empathetic. The Trust’s current actions do not fully address the failings and impact caused to Mr A and his family.
88. We also found that the Trust said in its complaint response, that it used the Waterlow tool during Mr Fawcet’s admission to decide his pressure sore risk. However, we have not found any evidence Waterlow was used. We think in the Trust not using an appropriate tool has stopped the Trust monitoring his pressure sore risk properly.
89. We do not find the Trust’s failure to manage Mr A’s pressure sores caused him avoidable pain. As we explained above, the Trust managed Mr A’s pain in line with relevant guidelines and there is no evidence in the records that he was in pain other than on those two occasions. Mr A had no feeling in his legs by the time he developed pressure sores, therefore he did not feel any pain from these sores.
90. We found the Trust missed a chance to refer Mr A to neurology sooner on 6 May. This caused a two-day avoidable delay in Mr A being under specialist care. This contributed to the delay to diagnose Mr A sooner.
91. Mr O says the Trust’s actions contributed to Mr A’s death in terms of speed and response because of its late diagnosis and treatment. Given the very serious issues Mr A had with his health, we cannot to say the twoday delay contributed to his death. But the delay did likely stop Mr A receiving a diagnosis and treatment sooner.
92. Finally, we found that during Mr A’s admission the Trust did not take steps to rule out or diagnose a spinal stroke.
93. Mr A was first suspected of having a spinal stroke on 8 May. The Trust did not take steps to assess him for a stroke until 12 May. This was a fourday avoidable delay from when a stroke was first suspected. As already explained above, Mr A should have been admitted to a stroke unit and reviewed within 24 hours.
94. Mr A was moved to another Trust’s specialist stroke unit on 15 May. Following an MRI scan on 17 May it diagnosed him with a spinal stroke. This was included as a contributory factor to Mr A’s death on his death certificate.
95. We asked our neurology adviser if a spinal stroke was present before 17 May. Our adviser said that on 12 May, when the Trust stroke consultant reviewed Mr A, he had a low spinal sensory level below T3/4 – vertebrae in the middle section of the spine. They said that indicated a spinal lesion such as a stroke was likely there.
96. Our neurology adviser said there were indications earlier and this was on 8 May when Mr A had focal neurological symptoms and that this alone should have triggered a referral for a suspected stroke. Our neurology adviser said it is likely Mr A had a stroke on 8 May. We are sorry to share this with Mr O and his family.
97. We considered what would likely have happened if the Trust had referred Mr A to a specialist stroke unit sooner, and if it had diagnosed him with a stroke on 8 May.
98. NICE guidance says treatment is available in specialist stroke units for people with heart failure. It says ‘anti-hypertensive treatment in people with acute ischaemic stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues: hypertensive cardiac failure (heart failure)/myocardial infarction (heart attack)’.
99. Mr A’s primary cause of death was heart failure and a heart attack, the secondary cause was a spinal stroke. We think it is likely had a stroke been diagnosed on 8 May the Trust would have monitored Mr A’s heart more closely and moved him to a specialist stroke unit. This would be in line with the NICE guidance above.
100. NICE guidance also says ‘an acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patients. Regular multidisciplinary team meetings occur for goal setting’. Our neurology adviser said that had been Mr A been in a stroke unit he would have received care more focused on his stroke and cardiovascular symptoms. Our neurology adviser also told us that Mr A would likely have been monitored more closely.
101. There are published articles which say ‘data suggest that appropriate specialist management improves outcomes for medical emergencies’.
102. We asked our neurology adviser if Mr A’s death was avoidable had the Trust diagnosed the stroke sooner. They said Mr A’s death was unavoidable. Due to his medical history of heart disease, it is unlikely an earlier diagnosis would have stopped the heart attack Mr A died of. Our neurology adviser said that had Mr A been moved to a stroke unit on 8 May he would have received specialist and more focussed stroke-specific care. They did say that he might have survived a ‘few extra days’, but our adviser was unable to say this for certain.
103. We asked our neurology adviser if Mr A would have benefited from any additional medication had the stroke been diagnosed on 8 May. They said that given Mr A’s history of having previously had a stroke, the Trust was already giving him the medication he needed to treat a stroke.
104. Not moving Mr A to a specialist unit the Trust has denied him a more appropriate setting of care. We cannot say the outcome would have changed and it is likely Mr A would have still died from heart failure.
105. From the evidence we have seen it is possible Mr A may have survived a few more days. Had the stroke been diagnosed sooner and we think it is likely the Trust would have started heart monitoring and put Mr A in a more appropriate care setting such as a stroke unit. Sadly, the family will now never know if a sooner diagnosis of Mr A’s stroke could have given their father-in-law more time. Even though this likely would only have been a couple of days. This in itself is an injustice. We find that as the Trust did not take steps to diagnose the stroke sooner the family were not prepared for Mr A’s death as they did not know he had suffered an event as serious as a stroke.
106. Mr O and his family told us they feel betrayed, scared and hurt. We can understand why they would feel this way given they now know the care their father received was below the standard expected. We hope our explanations have fully explained to the Trust and Mr O what happened.
107. We therefore partly uphold Mr O’s complaint.