CCU move 29 December
21. Mrs E complains the Trust inappropriately moved her husband out of the CCU on 29 December to a respiratory ward. She says he then deteriorated the following day and had to be readmitted. We understand why Mrs E was so concerned about this move given Mr E was then readmitted a short time later.
22. The intensive care guidance explains that patients whose needs can be met through normal ward care in an acute hospital do not need to be placed in a critical care setting. This includes patients who have recently moved from a higher level of care, but their needs can be met on an acute ward with additional advice and support from the CCU team. It says this also includes patients who can be managed on a ward but remain at risk of deterioration.
23. Mr E was admitted to the CCU on 28 December due to requiring increased oxygen support. Mr E was placed on a non-invasive ventilator (NIV) which is where pressure is blown through a mask to help expand the patient’s lungs. Mr E was also receiving high flow oxygen.
24. At the time of discharge from the CCU on 29 December, Mr E’s oxygen requirements had dropped to 45 percent. He was continuing to alternate between receiving high flow oxygen therapy and NIV. The Trust said it deemed him stable enough to continue his respiratory support under a respiratory ward.
25. Our critical care adviser said a respiratory ward can safely deliver NIV and high follow oxygen therapy. As such, there was no change in the support Mr E could receive following this move.
26. Taking into account the evidence we have seen, we have found no failings in the decision to move Mr E from the CCU on 29 December. Mr E was able to continue to safely receive the treatments he was having at this time on a respiratory ward. This was in line with the intensive care guidance.
27. We were sorry to hear Mr E deteriorated following this and required readmission to the CCU. We know this must have been a very worrying time for Mrs E.
Symptoms 30 December
28. Mrs E says the Trust did not start treatment when her husband began to experience symptoms of rigidity and stiffness on 30 December. Mrs E says these symptoms indicated her husband had a neurological condition.
29. The Trust advised us that there were no documented concerns from a neurological perspective on 30 December. It said that it was only in the late afternoon on 31 January that Mr E began to show neurological symptoms. We can see this was an unexpected development as up to this point, the Trust were treating Mr E for COVID-19 pneumonitis.
30. The GMC guidance says when assessing, diagnosing, or treating patients, doctors must:
• adequately assess the patient’s conditions, taking account of their history, their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment • refer a patient to another practitioner when this serves the patient’s needs.
31. From the evidence we have seen in Mr E’s medical records, it does not appear staff documented him to be displaying any neurological symptoms on 30 December.
32. On this date at 3.45pm, a nurse noted Mr E had passed urine using a bottle. A physiotherapist also reviewed Mr E at 4pm and noted Mr E was able to participate in his physiotherapy session. Both these entries imply that Mr E did not have the neurological changes which nurses documented he had the following day.
33. The next nursing entry at 4.30pm on 31 December noted Mr E was not able to move and lift his arms. This was the first point at which there is documented evidence he had a neurological change.
34. The observations charts from 31 December show a general elevation in Mr E’s National Early Warning Score (NEWS) around the same time. NEWS is a system which hospitals use to identify and respond to patients at risk of deterioration. The higher the score, the more at risk a patient is.
35. We can see that around 4pm, Mr E’s NEWS score rose from a ‘6’ to a ‘7’ and continued to climb. Our physician adviser said this corroborates the Trust’s view that the acute change in Mr E’s condition occurred around this time on 31 December.
36. We have not found the treating team missed an opportunity to consider a neurological change on 30 December. We have taken account of Mrs E’s recollection that her husband started experiencing these changes on this date. However, on balance, we are persuaded the neurological changes began to occur on 31 December.
37. When the treating team became aware Mr E was displaying neurological symptoms on 31 December, a doctor reviewed him promptly. The treating team began to think of a range of neurological conditions and arranged tests for this including blood tests and a CT scan.
38. We have found no failings in this part of the complaint as it appears the Trust acted in line with GMC guidance. We hope this provides some reassurance to Mrs E.
MRI scan
39. Mrs E says the Trust failed to perform an MRI scan to check Mr E’s neurological status as recommended several days before his death. Mrs E says an MRI scan provided after the Trust transferred her husband to another hospital showed a catastrophic stroke and that her husband was brain dead. We understand why Mrs E strongly feels this should have occurred much sooner.
40. Our critical care adviser explained that Mr E had developed a progressive neurological impairment starting on 31 December until becoming completely unconscious on 2 January. They explained the repeat CT scan Mr E had at this time was suggestive of multiple strokes.
41. We can see that at approximately 9pm on 3 January a CCU doctor spoke to a neurosurgical registrar at another hospital. They agreed the CT scan was suggestive of multiple strokes and to carry out further investigation through an MRI scan.
42. The stroke guidance explains that when doctors suspect a patient of having a stroke in the hospital setting, they should receive brain imaging urgently. The guidance says this is usually by a CT scan. However, the guidance also says an MRI scan should be performed in patients with suspected acute stroke when there is diagnostic uncertainty. The stroke guidance does not say how quickly an MRI scan should occur.
43. The medical records show the Trust suspected Mr E of having a stroke based on the results of his second CT scan. Our critical care adviser said an MRI scan would have confirmed the diagnosis and showed the extent of brain damage better.
44. Initially when it responded to this part of the complaint, the Trust said the scan had been requested on 2 January at 1.31am meaning it was to be completed in 24 hours. It said that usually once the request is made there will be a discussion between ICU and radiology which would be the normal process in this case due to the urgency. It said as the request had been submitted in the early hours of the morning it appears it was not handed over to the day team and subsequently the discussion was not had with radiology. It said this meant the scan was not placed on the priority list.
45. The Trust explained in its second complaint response that performing an MRI scan on a ventilated patient is a complex procedure requiring more than the usual level of staffing, one being an anaesthetist due to the equipment that must be redirected and remain attached throughout the procedure.
46. The Trust said to perform this procedure safely it was delayed by three days to ensure that the appropriately skilled staff were available to support Mr E through the MRI. As we know, the Trust transferred Mr E to another hospital before Mr E had this.
47. Our critical care adviser said that performing the MRI scan would not have stopped the progression or reversed the damage that had already happened. He explained it was to confirm the suspicion of the stroke and assess the extent of the damage. When Mr E had the MRI scan after the transfer, this confirmed the suspicion.
48. In summary, we can see the Trust initially performed a CT scan in line with the stroke guidance and when this was unclear the plan was to perform an MRI scan. There were no definite timeframes for how quickly the MRI scan should occur. We have also factored in the complications explained by the Trust in performing an MRI on a ventilated patient.
49. However, the Trust has acknowledged that it would usually perform these within 24 hours. It has confirmed this did not happen as it mistakenly did not place Mr E on the priority list. Although we acknowledge the Trust also had staffing issues at this time, there is nothing in Mr E’s medical records which mentions why there was a delay. Taking this into account, we do consider there was a failing here which the Trust has already acknowledged.
50. We can see Mrs E believes had the Trust performed the MRI scan, it would not have transferred her husband to another hospital if they knew how serious his condition was. The Trust acknowledged this in its complaint response, stating that if they had been aware of Mr E’s prognosis, the decision to transfer him would have been very different and that Mr E would not have met the criteria for discharge. It acknowledged it would not have made the transfer if it had known.
51. We can see that she had to make a 100-mile trip to see her husband and say her goodbyes. We can see this was an upsetting and traumatising experience for her at an already difficult time.
52. The Trust has already acknowledged this failing and apologised for the impact it had on Mrs E. It explained it had shared this incident with the critical care team to avoid this happening again. We have made an additional recommendation to the Trust to address this.
Transfer
53. Mrs E complains about the Trust’s decision to transfer her husband to another hospital without her consent. Mrs E says the Trust did not follow protocols in reaching this decision and questions if the Trust gave the receiving hospital full details of Mr E’s condition. We understand why this has caused Mrs E such concern given how unwell Mr E was at the time.
54. As stated above, had the Trust done an MRI scan prior to the transfer, the Trust may not have transferred Mr E. However, we considered if the Trust made this transfer in line with national guidance on the basis of the information they had at the time.
55. The NHS England guidance outlines the indications for when hospitals can transfer a patient. This includes when the treating CCU needs to create capacity to facilitate emergency or urgent critical care for other patients. This is known as a non-clinical transfer.
56. The critically ill adult transfer guidance also endorses making emergency transfers when there is a surge of demand in a hospital setting. This guidance says a contentious issue which sometimes arises is when a transfer is necessary because of lack of availability of critical care beds. However, it advises that on occasion this may be the most pragmatic approach, particularly where the transfer is required to generate capacity.
57. We know Mr E was in hospital during the COVID-19 pandemic. The Trust explained in its complaint response that at the time of these events, its CCU’s were facing extreme pressure and there was sadly a need to perform non-clinical transfers. It said at the time, the CCU team deemed Mr E to be one of the most stable patients within the unit.
58. The NHS England guidance does state that any decision to undertake a capacity transfer should be made with the agreement of the patient (if they have the capacity) or the patient’s next of kin.
59. However, the critically ill adult transfer guidance does not require organisations to obtain consent from the patient’s family when reaching decisions to transfer a patient. This guidance is clear the decision on this ultimately lies with the clinician in attendance.
60. We recognise there is a discrepancy between these two sets of guidance. However, our overall view is that the decision on whether to transfer a patient lies with the attending clinician. We would not have expected the Trust to obtain consent from Mrs E prior to transferring Mr E in line with the critically ill adult transfer guidance. The guidance does require organisations to communicate any decisions to the patient’s loved ones though and we have explored this further in the next section of this report.
61. We understand Mrs E is also concerned the Trust did not give the receiving hospital adequate details of Mr E’s condition prior to transferring him. However, we can see the transfer request form did include a detailed overview of Mr E’s condition.
62. Our critical care adviser had no concerns about the decision to transfer Mr E. This appears to have occurred in line the NHS England guidance and critically ill adult transfer guidance. Taking the above advice into account, we have found no failings in this area of the complaint.
63. Whilst we can see no failings in this decision, we acknowledge this was a far from ideal situation, sadly caused by the increased demand during the pandemic. We are in no way underestimating how distressing this decision was for Mrs E and her family at what we can see was already a traumatic time for them.
Communication about transfer
64. Mrs E complains the Trust did not notify her about her husband’s transfer to another hospital and incorrectly ticked a box on the transfer form that she had been.
65. The critically ill adult transfer guidance says that patients and their relatives should be kept informed at all stages of the transfer process. In line with this guidance, the Trust should have informed Mrs E of its plan to transfer Mr E at the earliest opportunity.
66. The Trust explained in its complaint response that at the time of the events, the unit was exceptionally busy. It explained the consultant delegated the responsibility of informing Mrs E of the decision to a junior doctor. It appears the junior doctor then did not do this but incorrectly ticked the box on the transfer checklist to say this had happened. The Trust said this was down to a human error.
67. Taking the above into account, we consider the Trust did not act in line with the critically ill adult transfer guidance in communicating with Mrs E about the transfer. We consider this to be a communication failing which the Trust has already acknowledged.
68. Mrs E told us the poor communication from the Trust made what was already a distressing situation much worse. We can see how upsetting it was for Mrs E to learn that the Trust transferred her husband without her knowledge. Mrs E only found this out when the receiving hospital contacted her.
69. The Trust apologised to Mrs E for this poor communication and the distress it caused. It explained it had discussed this at unit level with all grades of staff, at divisional level, and within divisional speciality meetings to ensure it learns lessons from this.
70. We can see the Trust has taken some good steps to address this issue and improve its service. We have made an additional recommendation to the Trust to help remedy this part of the complaint for Mrs E in the recommendations section of this report.
Lack of updates
71. Mrs E says the Trust did not proactively provide updates or adequate details after her husband’s admission including how unwell he was.
72. The GMC guidance says doctors must be ‘considerate to those close to the patient and be sensitive and responsive in giving them information and support’. As such, we would have expected the Trust to have kept Mrs E updated on Mr E’s condition if this is what Mr E wanted.
73. We have considered the Trust’s communication from both Mr E’s time on the respiratory ward and his time on the CCU.
74. Whilst on the respiratory ward, the medical records show there was a discussion with Mrs E on 28 December where the doctor updated her on Mr E’s clinical condition. The doctor noted they reiterated that Mr E was at risk of deterioration.
75. On 31 December when Mr E deteriorated there was a further discussion from a doctor shortly after this deterioration at 5:30pm. The doctor explained that Mr E was not doing well and that he may have encephalitis or a stroke. They documented Mrs E said she understood Mr E was not doing well.
76. There is then a further documented discussion on 1 January where Mrs E was updated on Mr E’s situation although there is no time recorded for this. It appears this was before the Trust transferred Mr E’s care to the CCU.
77. Once Mr E was under the care of the CCU team, we can see no evidence this team provided updates to Mr E’s family. We can see Mrs E called twice on 3 January 2022 for updates and staff advised her on both occasions a doctor would call her back. We can see no evidence this happened. As stated earlier in this report, the CCU team also did not inform Mrs E of the decision to transfer her husband to another hospital.
78. Mrs E says she was not informed her husband was unconscious or was suspected to have suffered multiple strokes. As stated earlier in this report, the CCU team also did not inform Mrs E of the decision to transfer her husband to another hospital
79. Overall, we consider the level of communication from the Trust to Mrs E was not in line with the GMC guidance. We have seen there is some evidence of discussions with Mrs E where staff conveyed, he was very unwell and had deteriorated while he was under the care of the respiratory ward. However, there was no evidence of communication at all once Mr E was under the care of the CCU team.
80. We consider this to be a failing as this was not in line with the GMC guidance. The Trust has also acknowledged its communication could have been better in its response to Mrs E’s complaint.
81. We can see this poor communication has again caused further distress to Mrs E at this traumatic time. The Trust apologised to Mrs E for the distress this caused. The Trust explained it had reminded staff of the importance of the level of communication given to relatives during the patient’s admission, particularly in critical care wards.
82. Again, whilst we feel these are appropriate steps to help remedy this part of the complaint, we have made an additional recommendation to the Trust to address this poor communication further.
Communication between Mr and Mrs E
83. Mrs E complains the Trust did not facilitate communication between her and her husband during his stay, including a video call, despite her being unable to visit due to the pandemic.
84. The NHS visiting guidance which was issued during the COVID-19 pandemic makes it clear that hospitals should be facilitating communications between patients and their families in some way. This guidance does not state what form this communication should take as this would be down to the individual hospital to determine.
85. The Trust has acknowledged that it had been using video calls during the pandemic to facilitate communication. Ideally and in line with the guidance, the Trust should have made this option of communication available to Mrs E.
86. We recognise that Mr E’s stay occurred at a pressured time during the COVID-19 pandemic. This is evidenced by the fact the CCU unit were making non-clinical transfers out of the hospital to create more capacity. This would have impacted on the treating team’s ability to facilitate such communication.
87. The Trust admitted in its response that it had not made the option of a video call available to Mrs E and her husband during his admission. It said it should have given Mrs E the opportunity to see her husband and for him to have heard her voice, even whilst he was unable to communicate.
88. We consider this to be a failing as the Trust did not make this option available to Mrs E in line with the NHS visiting guidance. We again can see this will be incredibly upsetting to Mrs E that she was denied this opportunity to see her husband and or him to hear her voice.
89. The Trust has correctly apologised to Mrs E that it did not make this this option available to her and for the distress this caused her. The Trust explained it had reflected heavily on this.
90. Given that visiting restrictions are no longer in place at the Trust, we do not consider the Trust needs to take any further action to improve its service in this respect. However, we have made an additional recommendation to it in recognition of the impact this failing had.