Medication administration and documentation
15. Miss and Mrs B complain a nurse administered the wrong medication to Mr B just before he died. They say they saw a nurse come out from behind the curtain where Mr B was, questioning a colleague about whether she had the correct medication. They say the nurse then wrongly denied they gave him it, when they said he no longer needed it as he was taking his last breaths. They complain the nurse did not record this properly in the medication chart. They are left without clear answers about whether Mr B had the medication. They think if he did, it contributed to his death.
16. The NMC standards for medicines management say you must make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, ensuring the signature is clear and legible. It also says where medication is not given, the reason for not doing so must be recorded. RPS and RCN guidance says such records are completed at the time of the administration/refusal, or as soon as possible thereafter and are clear, legible and auditable.
17. The medication chart and last days of life care plan notes show that hyoscine butylbromide was going to be given at 10.50am. This was for secretions and vomiting. In the last days of a person’s life, secretions (saliva and mucus) may build up in their mouth, throat or airway. It can cause a wet, gurgling or rattling sound when they are breathing in and out. Hyoscine butylbromide is given for this as it works by reducing saliva production to dry out the secretions. Hyoscine hydrobromide can also be given for this. As the Trust explained, this is why the nurse checked which one of these to give.
18. The hyoscine butylbromide is crossed out on the medication chart which indicates it was not administered. This is supported by the nursing notes which explain that on arrival when the nurse was about to give Mr B the medication, he was taking his final breaths so the medication was not needed. The nurse documented that she discarded the drug, witnessed by another nurse.
19. We understand the family dispute the Trust’s explanation and think the nurse did administer the medication. They highlight that the entry was signed. They say medications are only signed for after they are given. The guidance does not state that it must be signed for after it is administered, but states at the time of administration. We accept the Trust’s account that the nurse signed the medication chart at the time she was going to administer it, but did not give this as Mr B was taking his last breaths. This is clearly documented at the time in the records. There is nothing to suggest to us that the Trust has falsified these facts following the event. The Trust’s documentation is in line with the NMC standards and RPS and RCN guidance.
20. Based on the evidence we have seen, we are satisfied the nurse did not prepare the wrong medication to give to Mr B. And we have not seen any indication the nurse gave it in any event. The nurse acted in line with the relevant guidance. We have not found failings. We hope this is reassuring for the family as we appreciate they have had concerns about this since Mr B died.
Contact about clinical deterioration
21. Miss and Mrs B say the Trust did not contact the family soon enough to tell them about Mr B’s deterioration and they feel the Trust has given conflicting information about when he deteriorated. They also say the Trust did not contact the right family member as it should have contacted Mrs B. They feel they lost precious time with Mr B at the end of his life as they could have gone to the hospital sooner had they known.
22. The NMC code says nurses should share with people and their families, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively. There is also broad guidance in NHS England’s clinical standards. This says patients, and where appropriate their families, must be made aware of reviews and where this results in a change to their management plan they should be made aware of the outcome and relevant information. GMC guidance says you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
23. We asked our nurse adviser about Mr B’s deterioration to consider whether the Trust informed the family soon enough. Our adviser says the Trust would not have known to inform the family about any signs of deterioration when they visited the afternoon before Mr B died. This is because Mr B was unwell but clinically stable at that time. Our adviser says the records indicate Mr B’s deterioration was unexpected, because on 24 February the palliative care team documented in their assessment of Mr B that the goal was for him to be discharged home with extra support.
24. The records also show the medical team told Mr B’s family on 24 February (undated, but before 4pm) that although he was very unwell, he was not imminently dying. The aim at that point was to safely discharge him home. We are therefore satisfied the Trust could not have informed the family when they were visiting that day that Mr B was deteriorating or expected to die.
25. The records show Mr B started to become agitated and confused between 7.30pm and 8.30pm that day and the nursing team asked for the medical team to come and review him, as this was unusual for him.
26. At 10.55pm Mr B remained agitated, and had become hypoglycaemic (low blood glucose) and his oxygen levels had dropped. The medical team had not yet reviewed Mr B, but our nursing adviser says at this point, from the documentation showing Mr B was deteriorating further, the Trust should have contacted the family to inform them. We cannot see the Trust did this.
27. We understand the family think the Trust should have informed them at around 7.30pm due to what the Trust said about when Mr B was deteriorating. Whilst he had become agitated and confused between 7.30 and 8.30pm, the records do not indicate he clinically deteriorated until 10.55pm. Our nurse adviser said it is around this time the Trust should have tried to call the family to let them know the situation and change in Mr B’s condition.
28. The medical team reviewed Mr B at 11.50pm and the notes said the family needed to be updated on his condition. This was another opportunity to let them know what was happening sooner. But the nursing notes only document at 1.40am that staff attempted to call Mr B’s daughter. Based on the RPS and RCN guidance we referred to earlier, we can take this as the time or shortly after the time the call was attempted. We can see no reason for the nearly two hour delay in ward staff trying to contact the family after the doctor advised this. The Trust also attempted call to Miss B at 2am, and left a voicemail message.
29. The Trust says it did not consider Mr B to be entering the last phase of his life until 1.45am. But it did know he was deteriorating earlier in the evening. The evidence we have seen indicates it should have tried to contact the family in the evening to let them know, rather than overnight.
30. The family are also unhappy Trust staff did not attempt to call Mr B’s wife as it should have and only tried to contact his daughter.
31. Our Principles of Good Administration, say public bodies should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case.
32. Two of Mr B’s records documenting his family contacts note Miss B as the preferred contact and Mrs B as the second/alternative contact. But both were important contacts for Mr B and were contactable. Based on the information it had, it was not wrong for the Trust to try contacting Miss B initially. However, as it accepts in its response, when it could not get through it should have tried to contact Mr B’s wife as the second contact. There is no indication it did this. We have found the Trust did not act in line with our Principles, as it should have responded flexibly to the circumstances and realised it should try the second contact.
33. When we weigh up the evidence we have seen, we have identified failings. We think the Trust should have tried to contact Mr B’s family in the evening of 24 February, from 10.55pm when Mr B was clinically deteriorating. We also think the Trust staff should have tried to call Mrs B when her daughter did not answer their calls. We consider the impact of these failings below.
Impact
34. The family feel they lost precious time with Mr B at the end of his life. They find it very upsetting that it was noted he was distressed and agitated during this time and they could not be with him until the morning.
35. We cannot know if either Miss or Mrs B would have answered calls if the Trust had made them, and to both, in the evening rather than during the night. But it is more likely they would have. This was a missed opportunity for a number of things: to allow them to have spent more time with Mr B during his final night; to prevent Miss B waking up to a message about her father’s deterioration and having such little time to get there to be with him; and to better prepare the family for his death.
36. We can only imagine how difficult it has been for them feeling they may have been able to spend more time with Mr B before he died and why they have felt unable to grieve properly without answers. We appreciate this has made an already difficult time much harder for them, exacerbating their bereavement.
What the Trust has already done to put things right
37. The ‘NHS Complaint Standards’ state that NHS organisations should be open and honest when things have gone wrong, recognise when this has had an impact on people, and identify suitable ways to put things right. The NHS Complaint Standards say that NHS organisations should identify what learning they can take from a complaint, and where they can make improvements.
38. In its complaint response, the Trust did apologise for not trying to call Mrs B as the second contact. It said this is not what the matron would expect when there are multiple contacts documented. It said the matron would remind the nursing team they must always establish preferred contacts and that they should attempt to call all those named if the first named person cannot be reached.
39. We think the Trust’s actions on this point are in line with the NHS Complaints Standards. It has apologised and set out how it will make sure it follows due process in future. There is no indication its usual process for contacting a patient’s family members is outside of relevant standards, only that on this occasion staff did not follow it. There is more it should do to explicitly acknowledge the contribution this had to the impact on the family.
40. The Trust did not acknowledge it should have contacted the family earlier than it did about Mr B’s deterioration, acknowledge the impact this delay had on them, or take action to put things right.
41. There is more the Trust needs to do to fully acknowledge what it got wrong and the impact of its mistakes on Miss and Mrs B. It also needs to do more to show how it has learned from this complaint, and how it has taken or will take action to make sure this does not happen again.