Findings about the Hospital Trust
Complaint about intravenous (IV) diuretics and the increased dose of oral diuretics
23. Diuretics are medicines that help reduce fluid retention. They can be given orally in tablet form, or intravenously (where they are given via a drip into the bloodstream). Mrs W was on IV diuretics from 24 November to 1 December.
24. The GMC guidelines say doctors must prescribe drugs or treatment that serve the patient’s needs and is based on the best available evidence.
25. The heart failure guidelines say IV diuretics are ‘the most rapid and effective treatment for signs and symptoms of congestion leading to hospitalisation for heart failure’. Congestion refers to fluid retention.
26. Our physician adviser explained Mrs W needed treatment with diuretics because of the fluid retention in her legs. She was already on an oral dose, but her fluid retention in hospital increased so she needed stronger treatment to meet her needs. We therefore consider the use of IV diuretics was in line with the heart failure and GMC guidelines.
27. Our physician adviser explained there is no standard dose for diuretics. It depends on the individual patient’s needs.
28. The NICE guidelines say diuretics should be ‘titrated up and down according to need’. Titrated refers to changing the dose. The heart failure guidelines say this may involve doubling someone’s dose.
29. Reassuringly, this is what happened in Mrs W’s case. Her usual dose of oral diuretics was doubled after a course of IV diuretics, and she was discharged from hospital on this increased dose. Our physician adviser says this dose was appropriate to meet her needs. We found this was in line with the GMC, NICE, and heart failure guidelines.
30. We have also seen a clinician from Mrs W’s GP practice reviewed her diuretic dose on 13 December when she was at home and made no changes to it as it was suitable for her needs. We hope this gives Mrs J some further reassurance her mother’s diuretics were appropriate.
Complaint that staff did not recognise Mrs W’s legs were leaking fluid
31. In its complaint response, the Trust explained staff did not fail to recognise Mrs W’s legs were leaking fluid. The Trust referred to one occasion where staff noted this. Mrs J says her mother’s legs regularly leaked fluid after this admission when she was back in the care home.
32. Day to day, it is the responsibility of nursing staff to monitor and assess a patient’s skin integrity and escalate any concerns. The NMC code says nurses must: • keep clear and accurate records • preserve the safety of those receiving care • share information to identify and reduce risk.
33. Mrs W had fluid retention in both legs. Fluid leaking from the legs can be a complication of this and is caused by the fluid seeping out of the tissues through the path of least resistance.
34. The records show staff were aware of this potential complication. Nurses completed regular skin assessment, saw Mrs W had fluid retention, and monitored her legs. Medical staff observed Mrs W’s legs and noted her ongoing fluid retention and history of leg cellulitis (skin infection).
35. There were two occasions where staff noted Mrs W had fluid leaking from her legs. On 24 November a doctor noted her right leg was ‘weeping’. Then, on 3 December a nurse noted that a left leg dressing had become soaked.
36. There was no other documentation suggesting leg leaking was observed the rest of the time Mrs W’s legs were being monitored. For example, there was no other mention of wet bedding, dressings, or clothing.
37. We cannot conclude that staff failed to recognise Mrs W’s legs were leaking fluid or were not mindful of the possibility of this. It was documented when observed, and staff were regularly monitoring her legs. We found no evidence nursing staff did not act in line with the NMC code here.
38. As we address later in our report, we recognise Mrs W’s leaking legs went on to be an issue for her. We hope our findings here give Mrs J some reassurance about her mother’s care in hospital.
39. To further reassure her, our physician adviser explained even if Mrs W’s legs were leaking during the hospital admission, she was on the optimal treatment for this in the form of IV and oral diuretics.
Complaint about blood thinners being stopped and restarted
40. The GMC guidelines say doctors must prescribe drugs or treatment that serve the patient’s needs and is based on the best available evidence.
41. Mrs W was taking long term blood thinners for a heart disorder. Doctors temporarily stopped these on 23 November because she had anaemia. This is where someone does not have enough red blood cells to deliver oxygen around their body, or their red blood cells cannot carry enough oxygen.
42. Doctors needed to make sure the anaemia was not caused by an internal bleed, which would be made worse with blood thinners as they make blood flow more easily. Tests showed there was a different cause for the anaemia and, on 1 December, doctors decided it was safe to restart blood thinners.
43. Mrs W had a nosebleed on 5 December which was treated. Blood thinners were temporarily paused again and restarted on 7 December.
44. Our physician adviser said it was appropriate for doctors to pause and restart blood thinners. Mrs W had a heart disorder that required blood thinners, but these were stopped to meet her needs when there were concerns about the risk of bleeding. The doctor’s actions were in line with the GMC guidelines and we found no failing here.
45. We understand why Mrs J is concerned about her mother’s nosebleed. Our physician adviser explained although blood thinners can make bleeding worse, they would not be the cause of bleeding itself. Nosebleeds can be common in general, and made worse in people on blood thinners, but stopping and restarting this medication would not be expected to cause a nosebleed or make one more likely to occur.
Complaint about the discharge summary to the GP
46. The GMC guidelines say doctors must ‘contribute to the safe transfer of patients between healthcare providers’ and ‘share all relevant information’.
47. The BMJ guidelines say ‘the discharge summary should facilitate the safe transition of care from the hospital setting back into the community, delivering information that is both relevant and accurate to aid continuing care’.
48. Our physician adviser explained the key information the GP needed to know was that Mrs W had received inpatient treatment for heart failure and was going back to her care home on an increased dose of diuretics. We can see this information was included on the discharge summary.
49. Mrs J says the discharge summary should have mentioned her mother had received IV diuretics during the admission. We cannot see there was any need for this as it would not affect the GP’s management plan. The GP needed to know about her increased oral dose as it would continue going forwards.
50. Mrs J also feels the discharge summary should have included instructions to the GP to monitor her mother’s leg leaking and fluid balance. This is where the level of fluid someone takes in and passes are measured. It can be used in people who retain fluid.
51. Monitoring fluid balance was not part of Mrs W’s ongoing treatment plan, but diuretics were. Fluid balance monitoring was appropriately not included on the discharge summary for the GP. The key information was she needed diuretics to manage her fluid retention and as stated above, this was mentioned.
52. Regarding leg leaking, it appears this was not deemed to be a significant issue during Mrs W’s admission after only being observed on a couple of occasions. In any event, our physician adviser said this information did not need to be on the discharge summary.
53. Mrs W was under the community nursing team and it was responsible for assessing and treating this. Specific instructions to the GP about this were not necessary as there was nothing additional the GP needed to know or do to manage this.
54. We recognise it would have been Mrs J’s preference for the discharge summary to include as much information about her mother as possible. We have seen that, in line with the GMC and BMJ guidelines, the Trust provided the GP with the key information they needed to know, and no essential information was missed. We see no failing here.
Findings about the Community Trust
Complaint that nurses did not attend when they should have, and advice given to care staff
55. The NMC code says nurses should work with colleagues to preserve the safety of those receiving care. When sharing care with colleagues they should only delegate duties within the other person’s scope of competence and ensure they fully understand the instructions given.
56. Our nursing adviser explained of the aim of Mrs W’s leg care was to provide interventions to absorb the fluid leaking from her legs, which was a consequence of her chronic heart failure. The role of the community nurses was to assess for any signs of deterioration or infection.
57. The community nursing team identified Mrs W did not need specialist dressings for her legs. Instead, she needed something to soak up the fluid, such as absorbent pads. Our nursing adviser explained it is acceptable, and common, in these circumstances for nurses to share care with care home staff who can apply and change simple dressings and pads.
58. We therefore consider it was in line with the NMC code for the community nursing team to advise carers on 10 and 13 December to apply a temporary dressing to Mrs W’s legs to manage leaking fluid. On these dates it appears she did not require a visit as there was nothing clinically urgent, such as concerns about infection.
59. The community nurses completed their first in-person assessment on Monday 12 December. Their treatment plan was for nurses to visit Mrs W twice a week for leg care. The next visit took place on 15 December, meaning she was seen twice that week.
60. The visit after this was on Saturday 17 December. This was unscheduled and took place because care staff reported concerns of infection. No visits took place after this as Mrs W was in hospital.
61. We find nursing staff attended to Mrs W in line with the twice a week treatment plan for the short time she was back in the care home before being readmitted to hospital. This, along with the shared care with the care home staff, meant she received an appropriate level of leg care. Our nursing adviser did not identify any instances where more frequent care should have been provided.
62. We found the care provided was in line with the NMC code and saw no failings here.
Complaint about triage on 17 December
63. The NMC code says nurses must accurately identify and assess signs of worsening health in a person receiving care. They must also make timely referrals when any action, care, or treatment is needed.
64. Care home staff contacted the out of hours community nursing team at 11.23am with concerns Mrs W had an infection in her skin. The community nursing team got back in touch at 11.49am and completed a telephone triage. This is where they ask questions to identify the seriousness of the symptoms and decide how soon a nurse should visit.
65. The notes say, during this triage, care staff reported Mrs W’s left foot was leaking, and there was swelling, redness, and pain.
66. Our nursing adviser says these are signs of infection, and the nurse should have gathered more information during the triage. For example, they should have asked if there was any discharge, if the area was hot, or if there were there any other signs of infection in the body such as fever.
67. The Community Trust accepts this. In its response to the complaint, it recognised the nurse did not ask enough questions to see if there were signs of infection.
68. After the triage call the community nursing team decided Mrs W needed to be seen within 24 hours (level 3 priority). The Community Trust accepts this should have been a level 1 priority, meaning Mrs W needed to be seen within two hours. We can see this is reflected in its triage checklist, which says infected wounds should be seen within two hours.
69. As the nurse did not gather the appropriate information, and the call was assigned the incorrect priority response, we consider the triage was inadequate and not in line with the NMC code.
70. A nurse visited Mrs W at 5.50pm, however had the triage been carried out correctly, she should have been seen at least four hours earlier. This would have been 1.49pm at the latest.
71. Understandably, this delay was a serious concern for Mrs J. We consider the impact of the failings we have seen later in our report.
Complaint about the nurse’s assessment and record keeping on 17 December
72. Mrs J says the nurse who visited Mrs W completed a poor assessment and failed to identify her mother was unwell.
73. The Community Trust accepts the nurse’s record keeping was poor (as things the nurse said they considered were not documented in the notes) and says it therefore cannot be sure if the assessment was adequate. Mrs J complains about this poor record keeping.
74. The parts of NMC code stated in paragraph REF _Ref191638755 \r \h 63, that nurses must accurately assess for signs of worsening health, apply here. In addition, the NMC code says nurses must keep clear and accurate records.
75. Nurses should also check a person’s physiological observations if necessary. The NEWS guidelines explain physiological observations like blood pressure and heart rate are measured to look for signs of worsening health. A score (called the NEWS) is given based on the results. This score can help nurses decide if there are warning signs of infection or acute illness, and inform any decisions about whether a referral to another practitioner is needed.
76. The records of this visit are very brief. They say the nurse noted Mrs W had a swollen leg and it felt painful. They wrote that carers were concerned about infection but there were no signs of this, and the nurse dressed Mrs W’s leg.
77. The records from previous visits to assess Mrs W’s legs indicate the Community Trust has an ‘interim wound review’ template. Our nurse adviser explained this template show the minimum level of information nurses would need to gather to assess a wound and see if there were any potential signs of infection.
78. Things the template includes, but the nurse did not document, are signs of odour, the amount of exudate (fluid), the condition of the surrounding skin and wound edges, and the absence or presence of signs of local infection. Although the nurse documented there were no signs of infection, they did not explain why.
79. Our nurse adviser explained the nurse should have checked Mrs W’s physiological observations because care staff reported concerns of infection. The NEWS score would have helped identify any warning signs or need for escalation, but nothing was documented.
80. When the Community Trust investigated the complaint it spoke to the nurse, who said they checked Mrs W’s observations, examined her legs, and advised care staff to contact the NHS 111 telephone service for medical advice. None of this is documented.
81. This poor record keeping means we are not persuaded the assessment was adequate. Even taking into account the nurse’s comments to the Community Trust, we cannot see a detailed enough assessment was done to identify or rule out signs of worsening health. Therefore, we consider the assessment and record keeping were not in line with NMC code and there are failings here.
Impact of the failings we have seen
82. We thought about the impact of the failings on 17 December. These were the incorrect triage leading to a delay in being seen, and an inadequate assessment and record of the visit. Mrs J feels her mother missed a chance to go to hospital sooner, and this may have prevented her death.
83. The nurse felt there were no signs of infection, so they did not arrange any further treatment or investigations. Our nurse adviser says even if the visit had gone ahead four hours earlier, the findings and outcome of the visit could have been the same. We therefore cannot say the delay itself prevented Mrs W from going to hospital sooner.
84. Turning to the nurse’s assessment and record keeping, we cannot say, even with the benefit of hindsight, if Mrs W did or did not have signs of infection in her leg. The lack of any other information, even in the care home records, means we cannot say either way. This means we cannot conclude whether the nurse should have arranged hospital admission for Mrs W.
85. We note when Mrs W was later taken to hospital she was found to have sepsis of an unknown source, rather than originating from her leg. This means it may be the case the nurse correctly ruled out a leg infection. We will never know more than that.
86. Although we cannot conclude the failings had any clinical impact on Mrs W, we can see they did impact Mrs J. They caused her distress, and made her worry about her mother’s care and that it contributed to her death. This impacted her ability to grieve.
87. Our NHS complaint standards say organisations should take steps to put things right when their poor service has an impact on someone. They also say organisations should learn lessons from complaint to ensure poor service is not repeated.
88. The Community Trust has done this. In its responses to Mrs J’s complaint, it openly accepted it made mistakes on 17 December. It provided extensive and sincere apologies for what happened and recognised the impact this had on Mrs J. It explained to her what it will do to improve its services, and it produced an action plan for these improvements.
89. We consider the Community Trust has done enough to put these matters right, and there is nothing further we would ask it to do. We hope Mrs J can take some comfort from the Community Trust’s apologies and commitments to improve.
Findings about the Ambulance Service
90. Mrs J is concerned the paramedic’s assessment on 16 December was inadequate and her mother’s low temperature meant she needed to be taken to hospital for monitoring or checks for sepsis. The Ambulance Service says its paramedic conducted a comprehensive assessment and reached the right decision.
91. The JRCALC guidelines say paramedics should do initial checks to see if a person has any immediately life-threatening symptoms. As part of this they check a person’s physiological observations. After that, they should do a more detailed assessment which involves a ‘head to toe’ assessment of a person’s major body systems (such as respiratory, cardiac and neurological).
92. Paramedics need to consider if a person has sepsis. The JRCALC guidelines say paramedics should not use someone’s temperature as the sole predictor of sepsis. Paramedics should calculate someone’s NEWS score based on their vital signs, and suspect sepsis if someone has a score of five or more.
93. Our paramedic adviser told us the paramedic’s assessment was detailed and thorough. The records show the paramedic considered Mrs W’s major body systems (such as her respiratory and cardiac systems) and ruled out anything life threatening. They also checked her vital signs. We cannot identify anything that was missed or should have been done differently during the assessment.
94. The only abnormality of note was a low temperature. A normal temperature is between 36-38 degrees. Mrs W’s was initially 34.6, and it rose to 35.1 when the care staff took steps to help her get warm. This resulted in a NEWS score of one. Our physician adviser said this score was very low. In line with the JRCALC guidelines, a score of under five in someone who is otherwise well would not be an indicator for sepsis or acute serious illness.
95. We therefore found it was appropriate the paramedic did not arrange for Mrs W to go to hospital. Instead, they provided care staff with advice to keep her warm and told them what to do if she got worse or developed new symptoms.
96. Mrs J told us she would have liked her mother to be taken to hospital just in case. Our paramedic adviser explained it would not be appropriate to do this if there is not a clinical need for it.
97. We understand why Mrs J was concerned about this assessment, particularly as her mother was taken to hospital two days later. We hope our explanations here have reassured her that there was no failing in the paramedic’s care on 16 December.
Conclusion
98. We thank Mrs J for raising her concerns with us. In conclusion, we found no failings in the care the Hospital Trust or the Ambulance service provided to her mother.
99. We saw some failings in the Community Trust’s care on 17 December, which it accepts. We could not see these failings impacted Mrs W. We recognise Mrs J was affected, and we hope she is reassured to know the Community Trust has done what we would expect it to do to put things right for her.