Catheter
13. Mrs E says she told nurses that her father had pain in his groin on the night of 19 January 2022. Mrs E says the catheter had been blocked twice before during previous nights and needed to be washed out to remove sediment. She says nurses did not act for two full days and when they did so they found his catheter was kinked. She says her father later developed a serious urinary tract infection (UTI) and believes the blocked catheter caused this.
14. The NMC Code says nurses must deliver the fundamentals of care effectively. It says they should ensure any treatment or care is provided without delay and they should work in partnership with people to ensure they deliver care effectively.
15. The RCN Guideline explains how catheter care is a fundamental aspect of nursing care. It explains how nurses should check for and resolve catheter blockages. It refers to methods of maintaining catheters.
16. The clinical records contain a catheter care record. We can see a nurse started this record on 8 January 2022 when they first gave a catheter to Mr R. The catheter care record was incomplete, but nurses did complete the relevant section for Mrs E’s complaint several times over the following days. This showed that nurses checked the catheter on 16 January and then twice on 19 January and once on 20 January. They identified no issues with the catheter on those occasions. Other clinical records refer to different occasions when nurses checked Mr R’s catheter.
17. At 4.52am on 18 January 2022 a nurse noted an issue with the catheter, and this led to it being washed out to clear any sediment. This is one of the actions recommended in the RCN Guideline for addressing any blockage in a catheter. Later that afternoon a nurse noted the catheter was in position and was draining well.
18. Nurses also completed fluid balance charts for Mr R throughout the admission. These show the catheter was draining properly between 18 and 20 January 2022. This is also reflected in other clinical records.
19. At 9.37am on 20 January 2022 a nurse documented a conversation with Mrs E. The nurse noted Mrs E considered her father had pain in the area of the catheter, which she believed was blocked. The nurse carried out a bladder washout and noted some resistance and sediment.
20. At 4.35pm a nurse noted that staff had inserted a new catheter. This was because the catheter had again stopped working earlier in the day. This problem resolved once the new catheter was in place.
21. The Nursing Adviser told us nurses followed the NMC Code and the RCN Guideline. They provided appropriate catheter care. The records show there were occasions when Mr R’s catheter was blocked. Nurses responded to these incidents appropriately and promptly by carrying out bladder washouts. When problems persisted, as pointed out by Mrs E, clinicians replaced the catheter. We recognise this must have been frustrating for Mrs E. We find there were no failings in this respect.
Head injury
22. Mrs E says her father did not fall down the stairs. She says he was found slumped at the bottom of the stairs, against the door of his home, and that his face was droopy. She says there is no evidence he had a fractured skull with no bruising and so he must have had a stroke. Mrs E believes doctors failed to identify and treat the stroke and this meant they incorrectly assumed he was going to die from his injuries.
23. The Trauma Guideline explains how clinicians should manage patients who have experienced trauma. It says patients should be intubated (meaning a tube should be inserted) to ensure they can breathe if they cannot maintain their own breathing. They should use the FAST system to help with assessing the patient for chest trauma. This is an ultrasound examination of the body. The Trauma Guideline also recommends stopping any anticoagulants a patient may be taking.
24. The Head Injury Guideline says clinicians should establish whether a CT scan of the head is needed for people at high risk of having a clinically important traumatic brain or neck injury. It stresses the importance of CT scanning as the first line of investigation. It lists the risk factors for patients needing a scan, including reduced levels of consciousness.
25. A junior doctor reviewed Mr R in the emergency department. They noted he had returned from the pub. His wife noticed a light had been left on and went downstairs. She found him at the bottom of the stairs with his head against a door. There was then a delay of around one hour before Mr R’s family called an ambulance. On arrival paramedics had noted he had reduced consciousness, and they intubated him.
26. The emergency department records show doctors carried out a FAST scan to rule out any abdominal bleeding and then arranged a CT scan. They also stopped his anticoagulants. The clinical records referred to bruising on Mr R’s face and body. The Medical Adviser told us these actions were in line with the standards referred to above. They said the doctors followed a recognised approach for people with suspected trauma. The correct investigation for trauma is a CT scan, which is also an appropriate investigation to check whether someone has had a stroke. It appears the CT scan was arranged in a timely manner.
27. The CT scan showed significant bleeding in Mr R’s brain and a skull fracture. The doctors considered these to be severe injuries, and their view was that he may not survive them. Over the following days there was evidence of increased swelling in the brain along with further areas of bleeding. They advised the family that if Mr R survived, he was likely to be severely disabled.
28. The Medical Adviser said there is no evidence that Mr R had a stroke. The CT scan showed his head injuries were consistent with a fall and subsequent trauma and not a stroke.
29. We find doctors followed the Trauma Guideline and the Head Injury Guideline when investigating Mr R’s head injuries. We note Mrs E is unlikely to agree with our view. We would like to reassure her that we have reached this view based on the clinical evidence and the interpretation from our experienced Medical Adviser.
Hand
30. Mrs E says clinicians treated her father’s swollen right hand incorrectly. She recalls she had been advised to regularly massage her father’s hands. By 8 February 2022 she raised concerns about the swelling and recalls doing so again three days later. She says a member of clinical staff bent her father’s fingers back and this caused permanent damage. Mrs E sent us photographs showing her father’s swollen hand. She says her father still cannot move two of his fingers.
31. The Physiotherapy Adviser told us there are no specific standards relating to how healthcare professionals should manage patients who have swelling to their hands. The responsibility for such management would not lie solely with physiotherapists. However, clinicians should have followed the Rehabilitation Guideline. This stresses the importance of clinicians working as part of a team. It says they should assess the patient’s physical function. This includes assessing arms and legs and their range of movement.
32. The clinical records show physiotherapists regularly reviewed Mr R during the first three weeks of his admission to the Hospital. They made no record of any problems relating to Mr R’s right hand. During a physiotherapy review on 2 February 2022 Mr R groaned with pain when attempts were made to extend the fingers on his right hand. He was unable to fully extend his fingers. The physiotherapist produced a treatment plan, which involved massaging and stretching the affected area.
33. A rehabilitation assistant noted on 7 February 2022 that they gave a massage and gently stretched the fingers on Mr R’s right hand. There was a joint physiotherapy and occupational therapy review on 9 February. They noted Mr R remained in pain when his right ring and little fingers were extended. The next day a rehabilitation assistant saw Mr R. They noted they gently massaged Mr R’s right hand and referred to finger stretches.
34. On 11 February 2022 a nurse asked for a doctor to review swelling at the site of Mr R’s cannula. The doctor found no evidence of swelling around the wrists but documented that the right hand was ‘slightly puffy.’
35. An occupational therapist reviewed Mr R on 14 February 2022. They noted that his right hand remained in a flexed position. They said they attempted to stretch out some of his fingers without success. They said Mr R was clearly in pain when they manipulated his fingers, although he remained asleep throughout.
36. On 17 February 2022 a rehabilitation assistant saw Mr R. They carried out the recommended exercises and observed his movements. They massaged both hands and noted the swelling had reduced, but there was ongoing tightness in the fingers of his right hand.
37. The Physiotherapy Adviser told us there is no reference in the clinical records to Mr R sustaining an injury to his right hand. Neither is there any reference to a clinician bending his fingers back. The records show Mrs E was present during some of the therapy sessions when clinicians massaged or manipulated her father’s fingers. There is nothing to indicate that she objected to what they did at the time of the events. Doctors suspected the hand pain was related to the use of mittens Mr R was wearing to prevent him removing the lines and tubes that were in place.
38. During the early part of Mr R’s admission to the Hospital it would have been difficult for physiotherapists to carry out a full assessment. This was because of the seriousness of Mr R’s brain injury. The first opportunity to properly review his hand was on 2 February 2022. We cannot say this was a delay that fell below any relevant standards or guidelines. Physiotherapists appear to have followed the Rehabilitation Guidelines.
39. The Physiotherapy Adviser said there seems to have been a good approach to team working between different specialties. However, physiotherapists could have made a referral for a doctor to review Mr R’s hand on 15 February 2022. By this point Mr R was having difficulty moving his fingers. However, there is no clear evidence to suggest medical assistance was definitely required and there is no guidance about when a doctor should be contacted in these circumstances. In any case a doctor did review Mr R’s hand on 11 February and did not make any recommendations.
40. We find the clinicians followed the relevant standards when managing the problems Mr R developed in his right hand. We cannot see any evidence that Mr R’s problems with his right hand were the result of failings in management.
Palliative and end of life care
41. Mrs E questions the decision to give her father palliative care during his admission to the Hospital. She points out that he is still alive three years afterwards. She questions whether these decisions had an effect on her father’s long-term health.
42. The ICM Guideline is a guide to best practice in terms of decision making in critical care. It points out that up to 20 per cent of people in intensive care in the UK die in hospital. It stresses the importance of involving patients and those close to them in contributing to decision making when planning care.
43. The ICM Guideline says clinicians must be honest and clear about uncertainty and avoid giving firm predictions. It says they should provide individualised care plans depending on the patient’s wishes and circumstances. It does not indicate a point at which end of life care should start but explores a process by which that decision can be arrived at. It also says outcomes from critical illness are not only measured in terms of survival but also in terms of patient preferences about quality of life.
44. Intensive care teams often have to manage patients where the outcome is uncertain, while also continuing to deliver care and treatment. Part of this may mean exploring the appropriateness of palliative care and communicating this with family members.
45. The clinical records completed during Mr R’s admission to the Hospital show that clinicians involved his family in decision-making as they tried to understand Mr R’s likely wishes. By that stage Mr R did not have capacity to express his wishes. The treating team will ultimately decide how to treat a patient and determine what would be most beneficial for them. But it is good practice to consult with the family.
46. On 9 January 2022 a consultant discussed their understanding of Mr R’s injuries in a phone call with Mrs E. The consultant said Mr R had severe head injuries, but these were not considered ‘unsurvivable.’ They said surgery was too risky and they were aware from the family that Mr R would not want to survive if he could not live independently. The consultant planned to continue active treatment. There were further discussions with the family over the following days with doctors clearly noting their views. The aim was then for the focus to be on keeping Mr R comfortable and so he was placed under the palliative care team. This was in line with the family’s views.
47. During the first three weeks of Mr R’s admission clinicians continued to give him palliative care. But by 1 February 2022 his situation had improved. Doctors no longer felt he was approaching the end of his life. He was then given additional rehabilitation. The Medical Adviser said the evidence suggests doctors assessed Mr R holistically and, when his condition changed, they amended their plans. There is no evidence that doctors had started to provide end of life care for Mr R.
48. The Medical Adviser said recovery from a severe head injury is difficult to predict accurately in the early stages following the injury. During the admission neurosurgeons believed the extent of Mr R’s injury, his age and other health problems meant it was likely that there would be lasting impairment. There was no surgical procedure that would have been appropriate because of the high risks of causing further damage to the brain.
49. The Medical Adviser said the focus of early intensive care management after a head injury includes reducing the risks of, or minimising, further brain injuries and giving the patient a chance for the best possible outcome. The evidence shows doctors gave active treatment to Mr R in the hope that further recovery might be possible.
50. The Medical Adviser said there is no evidence the outcome for Mr R could have been improved further while he was in the Hospital.
51. We find doctors followed the ICM Guideline. There is no evidence their decisions were inappropriate. They clearly involved Mr R’s family in discussions about his prognosis. They correctly explained that Mr R was likely to have a lasting disability and took the family’s views into account when initially arranging palliative care for him. Clearly these were difficult discussions for Mrs E to be involved in and we recognise how distressing this must have been. We cannot say doctors made decisions that have had a negative impact on Mr R’s long-term health.
Conclusion
52. We recognise Mrs E has strong views about the issues we have investigated. She believes there were failings in care and treatment. We hope Mrs E is reassured that we have carefully reviewed the clinical records, with assistance from suitably qualified and experienced clinical advisers, and we have seen no evidence that clinicians fell below the relevant standards.
53. We do not uphold Mrs E’s complaint.