Nutrition
17. Mr H complains the Trust did not do enough to ensure Mrs H got adequate nutrition. He believes the doctors contributed to this by delaying fitting an NG tube with a bridle, delaying reviewing chest X-rays, and delaying prescribing an out of hours feed. We asked our ENT adviser and our dietitian adviser about what happened and where necessary, the impact of this.
NG tube bridle
18. It appears Mrs H had five NG tubes inserted during her hospital stay. A bridle was fitted to the NG tube on the fourth occasion, on 29 March, but this was not used until the fifth NG tube. The reason for this delay is not clear.
19. The Trust’s NG policy does advise that a NG tube bridle can be considered after two or more NG tubes have been inserted and removed. Therefore, a tube with bridle should have been considered sooner and could have been inserted on 24 March. As the Trust did not act in line with the policy, we consider it a failing this did not happen.
20. Our adviser said it is likely that, had a bridle been fitted on 24 March, the need to insert the last two NG tubes would have been prevented. It is unlikely that this delay caused any significant effect on Mrs H’s eventual outcome.
21. We hope this is helpful for Mr H. However, it is understandable that his family experienced frustration during his mother’s hospital stay as a result of the management of her NG tubes.
NG tube position
22. Appendix E of the Trust’s NG policy says a doctor should confirm the NG tube position within two hours of the chest X-ray. In the early hours of 26 March, there is reference in the nursing notes to not being able to use Mrs H’s NG tube as the doctors did not check the chest X-ray which took place on 25 March at 7.17pm until 9.54pm. This is also reflected in the medical records.
23. Instead, it took until 11:43 on 26 March for a doctor to say the NG tube was safe to use as long as the tube length had not changed. The Trust did not act in line with its policy, which we consider a failing.
24. The medical records show there were delays during the management of Mrs H’s NG tubes on various occasions. The Trust has not documented reasons for this in her records. Our ENT adviser said given the delayed check, the Trust should have considered a further X-ray to check the position if there was any doubt about the nasogastric tube having moved.
25. This additional check did not take place and we consider this a failing. We therefore looked at the possible impact this had. Our ENT adviser explained the risks from NG tube insertions include aspiration and chest infection or pneumonia. If the tube tip is in the wrong place, this is a major concern. We have seen no evidence this was the case for Mrs H.
26. We hope Mr H will be reassured by our view that in this case, the issues with the NG tubes are unlikely to have contributed to his mother’s death.
Out of hours feed
27. Our ENT adviser explained administering feed through the NG tube carries significant risk unless the tube is known to lie within the stomach. The Trust’s policy states that a gastric tube position should be checked by an X-ray prior to commencing feed. The whole process should be done ideally within daytime hours.
28. If this should extend beyond daytime hours, then the doctor needs to prescribe the nasogastric feed as ‘out-of-hours’. This is what happened in Mrs H’s case, but the prescription was done late in the day.
29. The nursing notes document nursing staff bleeping doctors several times from 18:54 on 21 March to prescribe an out of hours NG feed. A doctor prescribed the feed at 01:23 on 22 March. It is not clear what led to the delay so we consider there is a potential failing here, as the Trust did not act in line with its policy.
Alternative feeding
30. Our ENT adviser explained the preferred option of feeding Mrs H was via a NG tube and the Trust started this on 22 March. Alternative methods include total parenteral intravenous feeding (directly into the bloodstream), and insertion of a feeding tube directly into the stomach.
31. Mrs H was quite ill and frail during her hospital admission due to her pre-existing comorbidities and illnesses. These alternative interventional feeding techniques carry risk and therefore our ENT adviser explained they would have been inappropriate at the time of her admission.
32. Mrs H was referred for advice from a dietician, and the referral was made after six days of being in hospital. The first visit from the dietician was on 21 March. The notes indicate that there had been some difficulty in making contact with the dietician.
33. This was compounded by the feed being set ‘out-of-hours’. This required a doctor to prescribe the feeding regime. Again, there appears to have been a delay due to attempts to contact the on-call doctor.
34. Our dietitian adviser acknowledged ESPEN and NICE guidelines say other methods such as oral nutritional support and food fortification, as well as the eating environment, are considered in nutritional plans and advice. However, our adviser explained due to the SLT recommendations for Mrs H to be nil by mouth, this would have been inappropriate to have recommend.
35. In order to provide oral nutritional support, the patient needs to have a safe and functional swallow and this was unfortunately not the case for Mrs H. NICE guidance states that NG feeding should be initially trialled if a functional gastrointestinal system is present, which was the case for Mrs H.
36. Generally, clinicians will start with the least invasive option and provide regular review. In this case, the least invasive option was an NG tube and it should have been reviewed after two to four weeks to determine if longer term options, such as a PEG tube (to feed and give fluids directly into the stomach), would have been indicated. Unfortunately, the tube was removed and Mrs H passed away before this.
37. There are two methods available for confirming an NG tube is in the right position, aspiration and X-ray. The contents of the stomach is acidic so has a low pH level. Aspiration involves removing a small amount of fluid from the tube. If it has stomach acid in it, it will have a low pH. The Trust’s NG policy says this should be 4.5 or less.
38. The Trust was unable to obtain aspirate to check the positioning of the tube. Our dietitian said they would expect there to have been a Multidisciplinary team (MDT) meeting to discuss long term options for feeding if this had been indicated. This is because repeated removal, reinsertion and X-ray of the tube’s position, would have been distressing for Mrs H. It would also contribute to delays and non-consistent provision of the feed.
39. We have not identified anything went wrong in relation to this as Mrs H was approaching end of life care. This meant it was not necessary to have these discussions, as evidence and guidelines support the removal of the tube towards end of life, and moving onto comfort feeding only.
40. We considered if the dieticians gave appropriate advice about the management of Mrs H’s nutrition. The Trust used the MUST to identify Mrs H’s need for nutritional support and the need for dietetic involvement, in line with the BAPEN guidelines.
41. Mrs H had a ‘disease effect score’ of 2, indicating the need for a dietetic referral. This has been allocated due to a disease, or physical condition, severely impacting the individual’s ability to eat and drink. In this case, the mass in Mrs H’s throat and nil by mouth status being recorded by the SLT team.
42. Our dietician adviser noted the Trust’s records included all the relevant information needed to provide a full and accurate assessment. The clinical notes show the Trust carried out the initial assessment and three further follow up reviews whilst Mrs H was in hospital.
43. The Trust decided Mrs H should be nil by mouth following SALT recommendations on Friday 18 March. This prompted the referral, and the initial assessment took place on the next working day, Monday 21 March. We are therefore not critical of the time this took.
Diabetes management
Medication 44. JBDS-IP guidance covers ‘Commonly used insulin regimens’. The approach which uses intermediate-acting (basal) insulin, such as Humulin I, requires a single administration of isophane (NPH) insulin at the start of the feed, with a further dose likely to be required at the midpoint of the feed.
45. While the guidance came into force after the events, we consider it reflected what was considered good practice at the time. The advice from the diabetes CNS team to the ward was in line with this. We have not identified a failing here as the Trust acted in line with the JBDS-IP guidance.
46. On 23 March, the diabetes CNS documented ward staff had not followed their instructions for timing insulin with the start of Mrs H’s NG feed. Instead of giving Humulin I within the first few minutes of the feed starting, they gave it two and a half hours later. We asked our diabetology adviser about the possible impact of this.
47. Mr H is concerned that insulin should have only been given at the very start and midway of the feed in doses of eight and four units respectively. He says instead, the first dose was given two and a half hours after starting the feed with the second (three units) given three hours before the mid-feed time and then a third dose of six units was given two hours before the end of the feed.
48. The Trust’s records are consistent with this. They say insulin was given two and a half hours after the feed started, then three units were given seven hours after feed started, and six units two hours before the feed ended.
49. There is no dispute Mrs H received more units of insulin rather than the 12 recommended by the diabetes nurse specialist. The Trust’s 2024 complaint response acknowledged this and provided the Trust’s reasoning.
50. Our diabetology adviser explained the impact of the Humulin I being given later than advised by the CNS team was a larger elevation of blood glucose levels than if the insulin been administered in a more timely fashion, as advised. For people with type 2 diabetes, blood sugar level targets are 4 to 7 mmol/L before meals and under 8.5mmol/L after meals.
51. Mrs H’s blood glucose results between 17 March and 4 April were almost always in double-figures (10mmol/L or above) but infrequently greater then 20mmol/L. Whilst these levels are suboptimal, they would not have been dangerous. We therefore cannot see that the insulin administration affected Mrs H in the way Mr H was concerned it had.
52. The Trust’s response of 20 April 2023 acknowledges ward staff continued to give Mrs H sitagliptin (an oral glucose lowering therapy) on 18 and 20 March when the pharmacy had advised this should cease on 17 March. Our diabetology adviser explained whilst it would usually be withheld following the initiation of insulin, this is not always the case and it is licenced for use with insulin in the UK.
53. We appreciate Mr H’s account that his mother had tried sitagliptin at home the previous year and found it upset her stomach and gave her headaches. He says this is what prompted the pharmacy to try and stop her receiving further doses. We appreciate that if the medication did have this effect again, it would have added to her symptoms and discomfort.
54. Our adviser said sitagliptin is generally well-tolerated with few side-effects. As a glucose-lowering medicine, the use of sitagliptin with insulin has the potential to cause low glucose levels (hypoglycaemia), but this did not happen in Mrs H’s case. We therefore have not seen that the continued use of sitagliptin had any lasting negative impact on Mrs H.
Impact 55. Mrs H had a diffuse large B-cell lymphoma that was sadly incurable. Based on the advice we received, we consider Mrs H’s lack of recovery and frailty was due to her comorbidity and underlying tumour.
56. There is no indication from the advice our diabetology adviser and our ENT adviser gave that the issues we have identified in her care played a significant part in Mrs H’s death. We hope this will offer some reassurance to Mr H.
57. However, we can see these issues are likely to have contributed to Mrs H’s quality of life whilst she was an inpatient in the hospital. We also recognise her family’s experience of poor communication and learning of the poor care she received added to their bereavement.
58. Our diabetology adviser explained high glucose values, at the level experienced by Mrs H, can cause symptoms such as tiredness, thirst, blurring of vision and slow down the process of healing. However, older people often run with very high glucose levels without noticing any symptoms and this appears to have been the case for Mrs H.
59. The medical and nursing records do not suggest there were any concerns regarding Mrs H’s recovery from the biopsy and the glucose levels should not have influenced her eligibility for treatment of the underlying lymphoma (or other medical condition), had this been recommended by a specialist team.
60. We hope this investigation helps Mr H understand why we cannot link the treatment his mother received from the Trust with her death.