13. 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 in relation to most of the complaint.
14. The Trust has already acknowledged an error regarding Mr G’s medication. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have not found any indication that this issue had a negative impact on Mr G.
Testing for DVT
15. Mrs G complains the Trust did not check if her husband had a DVT. The Trust said there was no indication for such tests.
16. We understand Mr G had a previous diagnosis of DVT in March 2023, though we have not seen his previous medical records. Mrs G feels during the admission, the Trust should have scanned him or given a blood test to see if the clot was still there, and this might have saved his life. We appreciate she feels she has been left with uncertainty around this.
17. GMC ‘Good Medical Practice’ says investigations or treatment doctors provide or arrange must be based on an assessment of the patient’s needs.
18. Our adviser noted there is no record about this other than reference to his past medical history of a DVT. There is nothing in the notes to suggests he had new symptoms suggestive of either a DVT or a pulmonary embolus (PE), where the clot moves from the leg to the heart and lungs.
19. This means there was no clinical reason to look for a new DVT, and no reason to suggest a DVT from March 2023 would have moved. Our adviser explained by the time of this admission the clot would have been firmly adherent and extremely unlikely to move. Our adviser said there was no reason to suspect or investigate for a DVT.
20. We have seen no signs something went wrong in relation to this as the Trust’s actions reflect the GMC guidance. It may reassure Mrs G to know the treatment for a DVT or PE would have been full anticoagulation, which Mr G was already on.
Aspirin with rivaroxaban
21. Mrs G complains the Trust gave her husband aspirin on 7 and 8 October, when he should have been taking just rivaroxaban. The Trust has acknowledged an error and said it would not have caused any adverse effects.
22. Our adviser noted the list of Mr G’s drugs on admission included aspirin and rivaroxaban and that we are not able to determine where this information came from. However, our adviser said the prescription of both aspirin and rivaroxaban is given in patients with severe peripheral vascular disease, and in those with associated cardiac failure.
23. The BNF reflects that the combination of these two drugs can be associated with an increased risk of bleeding. It says they should be used together with caution or avoided.
24. We recognise how concerning this was for Mrs G. As the cause of Mr G’s death was listed as a coronary artery occlusion, a blockage, this ‘prescription error’ would not have made any difference to his outcome or the disease process. We hope our impartial view on this will be useful Mrs G.
Leg elevation
25. Mrs G complains the Trust did not elevate her husband’s legs. We can see the consultant and doctors had suggested he elevate his legs.
26. Our adviser acknowledged this is a difficult situation. With severe peripheral vascular disease (where the circulation is so severe that tissue damage occurs, as in this case), elevating the legs can be painful and patients often put their legs down due to this, despite doctors’ instructions.
27. The NMC Code says nurses must listen to people and respond to their preferences and concerns. They must respect a person’s right to accept or refuse care and treatment.
28. Our adviser noted Mr G’s legs were swollen due to his heart failure. Elevation in this situation causes the legs to ‘shrink’ which can also be painful. Mr G was also morbidly obese, which tends to make elevation of the legs ‘challenging’.
29. Overall, we cannot say something went wrong here. The instructions were advice only and there was no way to force Mr G to keep his legs up. It may be helpful for Mrs G to know our adviser considered this would have made no difference to his outcome or prognosis.
DNR decision
30. Mrs G complains the Trust put a DNR order in place without her or her husband’s agreement. The Trust disputes this.
31. The guidance says even when CPR has no realistic prospect of success, there must be a presumption in favour of explaining the need and basis for a decision not to attempt CPR to a patient, or to those close to a patient who lacks capacity. However, it is not necessary to obtain consent to the DNR decision if CPR has no realistic prospect of success.
32. A DNR order was put in place by a Trust consultant on 7 October, the day following Mr G’s admission when the management plan was agreed. This DNR records it was fully discussed with the patient. An entry by a doctor on 10 October documents a DNR discussion with Mr and Mrs G. It says ‘discussed DNAR and the reason for this, explained resuscitation was unlikely to be successful. [Mrs G] understood this and thanked me for my update’.
33. We are sorry to hear Mrs G does not recall being given information at the time. Based on the available information, it appears the Trust followed the guidance on DNARs.
Transport home
34. Mrs G complains the Trust did not transport her husband home when he was discharged on 12 October. She has told us how difficult it was for her to then get him into their home. We understand this must have made a difficult time even harder for them.
35. The Trust’s complaint response says an ambulance crew attended but could not take him home due to an emergency call, and the plan was then to arrange bariatric transport for the next morning. This is consistent with what we have seen in Mr G’s records.
36. It appears the ambulance crew attended to take Mr G home but he was not mobile enough to get into the ambulance. They planned to return with equipment to help him into the ambulance but were then called away to an emergency. They contacted the ward with a plan to return the following day, but Mr G did not want to wait so called Mrs G to collect him.
37. While the Trust was responsible for making arrangements for Mr G’s transport, the local ambulance trust was then in charge of deciding exactly how to get him home. We have explained to Mrs G how she can contact this organisation if she has concerns about its actions.
38. Overall, we have seen no reason to investigate the concerns Mrs G brought to us further. We recognise how much worry Mr G’s experience caused her and we would like to take this opportunity to thank her for bringing the complaint to us. We hope our decision will reassure her about the care Mr G received.