Concerns about care and treatment
25. Mrs J is concerned the failings identified in the safeguarding report and coroner’s report led to Mr P’s deteriorating clinical condition and sad death. Both Trusts accept the failings identified. We have summarised the main failings below.
26. The safeguarding report found staff at HCT did not act on Mr P not using his NIV regularly. This meant he was not receiving sufficient NIV support during his admission.
27. The coroner’s report found a consultant only reviewed Mr P 24 hours after his readmission to ENHT. This delayed his transfer to the RSU in turn delaying NIV support. They also found nursing staff transferred Mr P to the RSU without oxygen or NIV support in place.
28. The post mortem report found that although Mr P’s injuries to his spine led to his hospital admission they did not directly contribute or cause his death. Rather, his respiratory system was unable to clear high carbon dioxide levels and could not retain sufficient amounts of oxygen. This is known as type 2 respiratory failure.
29. NICE guidance shows type 2 respiratory failure can occur in patients with COPD who are late on in their disease. However, NIV support, by improving gas exchange, can reduce mortality by 50%. It is the most effective treatment for patients with COPD.
30. Mr P was on long term NIV and oxygen support for his COPD and sleep apnoea. At the time, NIV and oxygen support were effectively managing his breathing and respiratory conditions.
31. During Mr P’s second admission to ENHT, his arterial blood gas (ABG) tests also show how NIV was benefiting his condition. An ABG is a blood test taken from the artery to measure the amount of oxygen and carbon dioxide that moves from the lungs to the rest of the body.
32. The blood oxygen measurement shows how well a patient’s lungs move oxygen from the air into the blood when they breathe. The carbon dioxide measurement shows how well a patient’s lungs remove carbon dioxide from the blood when they breathe. If a patient has too much carbon dioxide, their blood can become too acidic, which can become life threatening.
33. Mr P’s ABG results were:
Date and time Oxygen measurement (a normal measurement is more than 8) Carbon dioxide measurement (a normal measurement is less than 6) 4.05pm on 3 January 2020 (no NIV) 8.6 16.1 10.23pm on 3 January 2020 (no NIV) 5.1 20.7 7.30pm on 4 January 2020 (NIV) 8 16.5 1.38am on 5 January 2020 (NIV) 7.9 11.5
34. It is important to note that Mr P was receiving oxygen support during this time which would have increased his oxygen measurement. As detailed by the NCBI study, oxygen support will increase the measurement of oxygen on an ABG test but is unlikely to significantly lower the measurement of carbon dioxide.
35. Overall, when Mr P was not on NIV support, his ABG results show his lungs were not moving high levels of oxygen from the air into his lungs. When Mr P was on NIV support, his ABG results show his body was moving more carbon dioxide from his blood, steadily bringing it down to a sufficient level.
36. Our adviser explained that although Mr P’s carbon dioxide levels remained high, he was only on NIV support for a small amount of time. His carbon dioxide measurement shows this was falling with NIV support and, on balance, it would have likely fallen further if NIV support was continued.
37. When Mr P was admitted to HCT, he did not receive NIV support regularly. Our adviser explains the omission of NIV treatment led to him retaining an increased level of carbon dioxide and not enough oxygen. This caused him to become drowsy and confused during his admission.
38. As this continued for a prolonged period, Mr P’s condition deteriorated, and it became increasingly more difficult to place him back on NIV support. Had staff raised concerns about Mr P not wearing his NIV sooner, they could have ensured an effective plan was in place for him to receive sufficient NIV support.
39. As this did not happen, Mr P required readmission to ENHT for severe type 2 respiratory failure. Here, the AMU consultant did not see him for 24 hours. During this time, Mr P was not seen by staff specialising in respiratory conditions, was not moved to a RSU bed and did not receive his NIV support initially.
40. Although he was receiving supplementary oxygen, this did not help remove the excessive carbon dioxide his respiratory system was retaining. Only NIV would have supported him with this. NIV support was only restarted in the evening of 4 January 2020, over 24 hours after his admission.
41. If the AMU consultant had reviewed Mr P sooner, they would have referred him to the respiratory consultant for admission into the RSU sooner. Staff in the RSU are trained and experienced in providing patients with breathing support, such as NIV, which would have benefitted Mr P.
42. At this stage, Mr P’s clinical condition was already poor as he had not received sufficient NIV support for a prolonged period of time at both Trusts. Although NIV helped to improve his condition when he eventually received this on the evening of 4 January 2020, it was stopped again prior to his transfer to the RSU.
43. We know the nurses who transferred Mr P have differing accounts of why he did not receive NIV support during transfer. They did not clearly detail how long Mr P was not receiving NIV support for while preparing him for transfer and during the transfer. To help us understand what happened, we have set out their accounts below.
44. One nurse explains she completed a set of observations at 12pm. Mr P’s NEWS score was 3 at the time. They gave Mr P nebulisers and antibiotics prior to transferring him. Another nurse documented the transfer actually began after 2pm at which time his NEWS had deteriorated to 5.
45. Mr P’s clinical notes made at 2.25pm say the nurse disconnected his NIV and ensured the battery backup was working. Another nurse noted the NIV machine “was not even turned on”. It is not clear if the battery pack was working, or the nurse did not turn this on prior to transfer. It is also not clear if the oxygen machine was on during transfer.
46. When Mr P arrived at the RSU, the critical care consultant confirmed he had sadly died. They explained Mr P had likely been dead for at least half an hour as he was pale, grey and his body was partially tense. They said this was roughly at 2pm.
47. Having considered these differing accounts, along with Mr P’s medical records, we consider there was a period of roughly two and a half hours where Mr P does not appear to have received NIV or oxygen support.
48. Mr P should have been transferred with NIV and oxygen support. There is a clear safety issue here and the nurses should have realised Mr P was not receiving this support and acted on it.
49. Our adviser explained it is likely NIV support would have continued to be effective in supporting Mr P’s lungs if staff at ENHT had continued it to the RSU. This is because, as we have seen above, NIV effectively helped manage Mr P’s condition before his initial admission. NIV also improved his ABG when he received this between 4 and 5 January 2020.
50. Although there is uncertainty about when Mr P’s NIV machine was switched off, or if it was turned on in the first instance, the evidence shows Mr P was not receiving NIV support at the time of his transfer. Our adviser explained that this, combined with the other failings identified, contributed to Mr P’s sad death.
51. Taking this into consideration, we find Mr P would have had a greater chance of survival had he received sufficient NIV support during his admission at both Trusts. To comment on the likelihood of this, we have carefully considered his Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) score and NIVO score.
52. The DECAF score helps predict the mortality of patients hospitalised with an exacerbation of COPD. To do this, clinicians consider various parameters regarding the patient’s clinical condition. Our adviser explained Mr P’s DECAF score was a maximum of 4. This predicts the risk of death during admission at 31% or less.
53. The NIVO score helps predict the risk of deterioration of patients with COPD who are receiving NIV support. To do this, clinicians consider various parameters regarding the patient’s clinical condition. Our adviser explained Mr P’s NIVO score was a maximum of 5. This predicts the risk of death during admission at 35% or less.
54. Taking this into consideration, we can see that if Mr P had received sufficient care and treatment during his admissions, the likelihood he would have survived to discharge was over 50%. This means Mr P would have had a greater chance of survival had the failings not occurred.
55. We have carefully considered whether both Trusts have taken any action to learn from what happened to Mr P and improve their service. We have also considered what they have done to help put matters right for Mrs J and her family.
56. Our Complaints Standards explain organisations should support and encourage staff to be open and honest where improvements can be made. Staff should recognise the need to be accountable for their actions and identify what learning can be taken. They should be clear about how the learning will be used to improve services.
Actions already taken by HCT
57. The safeguarding report asked HCT to consider what training it should give to ensure staff are aware of how to care for a patient on NIV. It said staff should also be aware of how to escalate care for these patients when they are refusing NIV treatment.
58. HCT told us that it took the following actions following the safeguarding report.
59. In January 2020, staff received training on advanced care planning. In February 2020, staff received training about communicating care needs to the family and carers of patients. In August 2020, staff received training on Continuous positive airway pressure (CPAP) and Non-Invasive Positive Pressure Ventilation (NIPPV).
60. HCT has told us it has provided advance care planning and respect training for staff. It has implemented improved communication processes to ensure nursing staff escalate concerns to the ward doctor and out of hours services in a timely manner to support safe patient care in its rehabilitation units.
61. HCT also says it has updated its referral form to show that patients with NIV need to be self-caring with their machines before admission.
62. We are concerned these actions are mostly one-off training sessions rather than embedded training for staff. This risks learning being lost and the failings we have found happening again. We query what HCT does when patients are referred who are not self-caring with NIV.
63. We also feel HCT could do more to address the impact on Mrs P’s family. We have commented on this further below.
Actions already taken by ENHT
64. ENHT says at the time of Mr P’s admission there were two consultants who provided cover for the ED and AMU. They had to review all new admissions on both wards, as well as carry out care rounds. ENHT decided this workload was excessive and caused a delay in patients being seen.
65. To ensure the ED and AMU ward had sufficient consultant resources, ENHT has hired two more consultants to cover the weekend. This means there are now four consultants at any one time during the weekend, which helps ensure patients are seen and reviewed more quickly.
66. In addition to this, ENHT also has a clinical care co-ordinator in the ED and AMU who ensures patients are being assessed and transferred to different departments accordingly. This ensures patients now receive prompt speciality review.
67. ENHT has also hired a transfer nurse to ensure patients are transferred to and from the AMU appropriately. The nurse will assess if a patient is fit for transfer and ensure appropriately trained staff are involved in the transfer. This helps improves patient safety and mitigates the risk of wards being left with reduced nursing support when patient transfer is needed.
68. Finally, ENHT has also increased bed capacity in the RSU. It now has 12 RSU beds available (instead of six), so appropriately trained staff can safely support more patients who require NIV. This reduces the likelihood of patients being left in the AMU for longer than necessary. It also helps ensure support is provided promptly to patients who need it.
69. We can see these actions are in line with our Complaints Standards. They help ensure the failings identified do not happen again. They also help ensure other patients are not left without NIV support, as in Mr P’s case.
70. We consider these failings sufficiently help put matters right by improving the service ENHT provides overall. However, we feel it could do more to address the impact on Mrs J and her family. We have commented on this further below.
Concerns about end of life care
71. Mrs J is concerned staff at HCT did not tell her or her family Mr P was on end of life care. This is because the safeguarding report refers to this. She explains this meant the family could not spend sufficient time with him before he sadly passed away.
72. Having considered Mr P’s medical records from both Trusts, we cannot see any evidence to suggest Mr P was on end of life care. Our adviser has also confirmed this was never initiated.
73. GMC guidance explains clinicians must be considerate and compassionate to those close to a patient and be sensitive and responsible in giving them support and information.
74. We can see staff at HCT attempted to discuss end of life care with Mr P on 26 December 2019, but this was not mentioned again, nor was it initiated. Mr P was on active treatment at both Trusts, which staff made his family aware of.
75. Staff here acted in line with GMC guidance by providing his family with the information they needed at the time. As he was not on end of life care, we would not have expected staff to tell his family this.