Removal of cardiac monitor
12. 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. We have done this and have not found any indications that something has gone wrong.
13. Ms E told us her father’s cardiac monitor was removed during the last days of his life. Ms E says her father should have been on a cardiac monitor. We recognise why Ms E does not understand why a cardiac monitor was used though he was on oxygen.
14. The Trust explains Mr E was deteriorating despite the treatment he was being given. The Trust says following discussions with Ms E and the palliative care team it agreed to make Mr E comfortable. The Trust says from this point on it would not use cardiac monitors as the noise from the machine can be distressing and the attachments can be uncomfortable and limit movement. It says a cardiac monitor was not necessary because it was not going to make any urgent treatment decisions.
15. The clinical records show Mr E was being actively treated but unfortunately his health declined. There is a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form in Mr E’s records. Records show on 4 October 2022 Mr E was placed on end of life care and this is evidenced by the Last Days of Life Care Agreement (LDLCA) dated 4 October. A LDLCA is a care plan for a patient who is going to die, which documents decisions regarding treatment and care alongside patient's and loved ones.
16. The DNACPR form recorded Mr E’s wishes, it says he did not want to be resuscitated.
17. Our adviser says it was appropriate to remove the cardiac monitor as Mr E was not going to have resuscitation and was being treated palliatively as he was sadly coming to the end of his life.
18. Palliative care is specialised medical care which relieves pain, symptoms and stress caused by serious illness. It helps people manage symptoms and focuses on making patients comfortable and reducing suffering.
19. Section 3 of the NMC Code is applicable here. 3.1 says nurses should, ‘pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages’ Section 4 of the NMC Code says nurses are to ‘act in the best interests of people at all times’.
20. Cardiac monitors make noise and there are wires which would be attached to Mr E’s chest, they would be uncomfortable and unnecessary when he was not in active treatment.
21. We know the monitor was not necessary as Mr E had reached a stage where he was not going to receive emergency treatment or be resuscitated, therefore his heart did not need to be monitored.
22. We consider the removal of the monitor was done in line with nursing guidance and with the aim of making Mr E more comfortable.
23. We have not seen any indication of failings with the Trust removing Mr E’s cardiac monitor and consider staff acted appropriately in doing so. We can understand that when the monitor was removed it would appear to Ms E the Trust had simply stopped caring for Mr E. We hope this explanation of why the cardiac monitor was removed reassures Ms E that was not the case.
Oxygen cannula
24. Ms E says the oxygen cannula caused sores on Mr E’s face and at the back of his ears as it was too tight. Ms E says Mr E was rubbing at the area, trying to show the nurses his discomfort and the nurses thought he was trying to remove the oxygen cannula.
25. The Trust says Mr E was on oxygen therapy as without it his oxygen levels would drop rapidly. The nurses implemented a Deprivation of Liberty Safeguards (DOLS) which allowed the Trust to place mittens on Mr E but he still tried to remove the devices which provided him with oxygen. The Trust says the cannula on Mr E’s hand was scraping on the skin on his face causing the sores.
26. It says Mr E developed a stage one pressure sore which is the least severe type of pressure sore. A stage one pressure sore is where the affected area of skin is discoloured, there is no open wound but the site may be uncomfortable and itch.
27. The Trust says the nurses took note of the sores and provided pressure care to prevent them from getting any worse. The matron apologised to Ms E that the nursing team did not communicate this aspect of Mr E’s nursing to her and the nursing team will work on communication as a result.
28. We have seen in the nursing records Mr E was placed on a nasal cannula on 22 September and he did not initially try to remove the nasal canula. This was first recorded on the 26 September when he first removed the oxygen cannula.
29. On 27 September it was noted in the records Mr E was not compatible with oxygen therapy, a DOLS was applied and mittens were fitted after multiple attempts at removing his nasal cannula. It is recorded he had mittens on and also tried to remove the venturi face mask and nebuliser mask. A venturi mask covers the mouth and nose and was used to deliver a higher dose of oxygen.
30. On 28 September it is recorded in the notes Mr E was removing his oxygen every three to five minutes.
31. Medical records note the nursing staff were aware Mr E was trying to remove his oxygen giving devices and nebuliser mask.
32. Staff fitted Mr E with mittens to prevent any damage to his skin. Our adviser says mittens would have been fitted to prevent any damage to Mr E’s skin when he tried to remove the nasal cannula or facemask.
33. It was important Mr E kept receiving oxygen as the medical records showed he did desaturate very quickly therefore, oxygen was medically necessary to keep him comfortable.
34. We understand why it would be distressing for Ms E to witness Mr E’s discomfort and his attempts at removing the nasal cannula.
35. The NMC code section 3 says to make sure people’s physical needs are assessed and responded to. The nurses noted Mr E was trying to remove his oxygen cannula and mittens were appropriately administered, this is something our nursing adviser agrees with.
36. We have not seen any evidence in the clinical records Mr E developed any sores on head and face, however after speaking with the Trust, the ward matron who was present at the time of events complained about told us,
‘I personally observed the nurses performing pressure area care around the patient's face, applying foam dressing to reduce friction. During this period, the patient was also placed on DOLS to prevent him from rubbing his face. The Category 1 (red, non-blanching) sore was monitored and remained unchanged throughout his stay (on the ward). I spoke with two of the staff who cared for him, and they confirmed this during my interviews with them. I was also present at the time of the patient's passing… I came to see the patient hence why I can confirm that the Category 1 sore did not progress to Category 2’.
37. We considered if Mr E received suitable pressure care, we understand his skin was nonblanching and unbroken and the nursing staff used a foam dressing to reduce friction.
38. The relevant guidance is CKS pressure ulcers and it says, ‘consider the need for pressure redistributing devices and tailor the support surface to the location and cause for the pressure ulcer’.
39. We consider the nursing staff treated the pressure sores on Mr E’s face in accordance with the guidance as they used a foam dressing tailored to his face and the areas of pressure caused by the cannula.
40. We have considered if oxygen could have been administered another way and saw there were occasions where a venturi face mask was used on 21, 24 and 29 September and 3 and 4 October. It is documented in the notes Mr E also tried to remove this mask.
41. The DNACPR form recorded Mr E’s wishes, it also says he did not want NIV. NIV is a method of administering oxygen to a patient without the use of a tube which delivers oxygen into the lungs (tracheal tube). Is it a sealed mask which blows the air into the lungs. It can be quite uncomfortable and is generally used in the short term to support a patient’s breathing while they recover.
42. Unfortunately, there was no other way of delivering oxygen to Mr E other than the cannula and face mask.
43. We understand it would be distressing for Ms E to witness her father’s discomfort and to watch him try to remove his oxygen cannula. We have seen the nurses took appropriate steps to ensure Mr E’s oxygen supply was maintained and they tried to minimise the damage to Mr E’s skin by using the mittens.
44. We have considered if oxygen could have been given to Mr E another way and saw Mr E was already being treated with oxygen using the least invasive method.
45. We have not found any indications of failing.
Water
46. Ms E told us nursing staff did not give her father water and they removed his water jug during his stay which caused him discomfort, a dry mouth and chapped lips.
47. The Trust says Mr E had water in the initial stages but this was removed as his condition deteriorated. It says the water was removed because it was not safe for Mr E to swallow and Mr E was given IV fluids to maintain his hydration. IV fluids are fluids such as water and electrolytes given intravenously (directly into the bloodstream).
48. We can understand why it would be distressing for Ms E to see that her father was not being given water.
49. The nursing records she Mr E was admitted on 20 September 2022. It is not recorded exactly when the water jug was removed.
50. We saw from the 28 September it was documented he was observed while eating, drinking and he was given assistance with these tasks which indicates the nursing staff had concerns for his safety.
51. Our nursing adviser says where patients had been assessed as having an unsafe swallow the water jug is removed. They explained it is common when patients are nearing the end of life, their swallow can become unsafe and they are at risk of aspiration (where food and liquids enter the lungs) which can cause infection.
52. Our adviser says Mr E was on intravenous fluids and therefore his body would not be dehydrated. However, we understand Ms E was concerned for Mr E’s comfort.
53. There are specific guidelines for mouthcare when drinking water is removed.
54. NG31, section 1.4 maintaining hydration 1.4.1 says, ‘to support the dying person to drink if they wish and are able to’. Records show nurses stayed with Mr E and observed him while he ate and drank.
55. NG31 section 1.4.2 says, ‘to offer frequent care of the mouth and lips to the dying person’.
56. We also saw in the records the nursing team provided comfort measures to Mr E on their rounds. When Mr E entered his last days of life on 4 October and was cared for by the Macmillan team it is documented they regularly provided mouthcare. As of the 4 October Mr E was on two to four hourly ward rounds and then from the 5 December he was on two hourly ward rounds. It is recorded in the notes sometimes his mouth was dry and mouthcare was given by staff regularly.
57. NG31 section1.4.3 says to ‘encourage people important to the dying person to help with mouth and lip care or giving drinks, if they wish to’.
58. Our nursing adviser says mouth care can be provided by families as it is personal care and often families like to do this for their loved ones to improve the comfort of their relatives.
59. Ms E says she brought in her own flannel to moisten Mr E’s lips and she put her own lip cream on to provide comfort.
60. We have seen mouth care was provided to Mr E when the nurses attended to him on their ward rounds and also by Ms E.
61. We have not been able to identify any indications of failings, as we consider the water was removed for Mr E’s safety. We saw Mr E was on intravenous hydration and mouth care was provided which was in line with the guidance NG31.
62. We can understand why it would seem cruel to remove Mr E’s water jug and we hope Ms E understands this was done for Mr E’s safety.
Contact
63. Ms E told us staff did not contact her when her father died on 6 October 2022.
64. Ms E said she went to visit her father on 6 October at approximately 3.25pm–3.30pm, she found him lying in his bed and it was clear he had died. Ms E was extremely distressed as she was not prepared to see her deceased father. Her daughter was with her and we recognise this was traumatising for them both.
65. The Trust says Mr E passed away unattended. This meant the Trust were not aware Mr E had died. The Trust says Mr E was being observed and was last turned by a nurse at 2.50pm. The notes record a nurse checked on Mr E at approximately 3.15pm and noted Mr E was breathing with shallow breaths and was asleep. The nurse placed a pillow under his head for support. It says Mr E must have died shortly after.
66. The records show on 4 October Mr E was moved on to end of life care as is evidenced by the Last Days of Life Care Agreement (LDLCA) of the same date. Hospital staff and family were aware Mr E was in the last days of his life. On 6 October Mr E was seen by a doctor at 9.30am and a note was made for him to be reviewed by palliative care.
67. At 10.06am Mr E was attended to by a nurse, who tried to give breakfast but could not rouse him and mouthcare was given. The notes say staff called Ms E, saying her father had not eaten and she advised she would come to see him.
68. The palliative care team visited Mr E at 11.15am and according to his prescriptions chart he was given glycopyrronium which is a drug given to treat respiratory secretions in palliative care.
69. On the symptom observation chart Mr E’s observations were recorded at 2pm and he was on two hourly ward rounds. On every ward round staff would record his observations in a chart.
70. There is a back dated entry at 4pm to say a nurse had checked on Mr E at approximately 3.15pm, they adjusted his position and placed a pillow under his head and noted his breathing was shallow.
71. The records say the family arrived at approximately 3.25pm-3.30pm and tragically found Mr E had died.
72. Ms E was understandably extremely distressed to find her father had died and says staff should have known and called her when he died. Ms E says rigor mortis had set in therefore, she thinks he must have been dead for a long time. We understand why this would be a great source of distress for Ms E.
73. Our adviser explained hospital staff cannot predict when a patient might die and sadly Mr E died unnoticed by the nursing staff. We cannot say exactly when Mr E died and think it was likely in between when the nurse last saw him at approximately 3.15pm and when Ms E arrived at approximately 3.25pm -3.30pm. There is no mention in the records of Mr E having rigor mortis.
74. We have not been able to find anything went wrong with the care Mr E was given, we have seen the nursing staff attended to Mr E regularly and maintained regular ward rounds as was required by the Last Days of Life Care Agreement.
75. It was extremely tragic Ms E found her father had died before she arrived. We recognise this was an awful experience for her and her family and we understand why they still feel traumatised. We hope our work provides her with the reassurance Mr E was not neglected.