11.Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation, in this case the Trust, has got something wrong. We do this by comparing what should have happened with what did happen and whether actions were taken in line with established professional guidelines and standards. We have done that and not found indications that anything serious has gone wrong in Mrs X’s care.
Placed a do not resuscitate notice on his mother’s record upon admission when it was too early to conclude this was in her best interests
14. Mr X says doctors placed a do not resuscitate notice on his mother’s record upon admission when it was too early to conclude this was in her best interests. He is also unhappy that his father was not consulted on this. He feels his mother’s dementia was used as a reason to not try to save her life.
15. Mrs X was admitted to hospital at 7pm on 17 January 2023. A DNACPR notice put in place at 8.14am on 18 January 2023 (approximately 13 hours later). The reason for not attempting resuscitation stated is ‘dementia, frailty, futility’. Mrs X, husband was informed of the decision shortly after.
16. A clinical note recorded on 28 January also details a discussion where Mr X felt doctors were giving up on his mother. This states it was explained that they were not, however, despite active treatment Mrs X was dying anyway due to not having the physical reserves to prevent infections spreading. The note states antibiotics would be continued but Mrs X was expected to (and did) continue to deteriorate and she eventually died.
17. GMC guidance on CPR explains that, while CPR can work in some cases (such as an acute accident causing an otherwise healthy person to go into cardiac arrest), it generally has a low success rate. Attempting CPR on a patient unsuccessfully may mean that the patient dies in an undignified and traumatic manner, as it often will result in damage to the ribs and internal organs. For this reason, the guidance states it is important to establish at the earliest opportunity if CPR would not work and place a DNACPR notice on the patient’s record, to minimise the chances of suffering an undignified death.
18. The guidance states that a decision to attempt CPR is a clinical decision based on the chances of CPR working. Our adviser said there was ample information available to make a judgement of CPR being futile when Mrs X was admitted to hospital due to her frailty. Mrs X was physically frail, partly due to her age and dementia, but she also suffered from pulmonary embolism (clots and scarring in her lungs reducing their effectiveness) and an enlarged heart due to progressive heart failure.
19. This meant that in the event that her lung or heart failed, CPR could not restore them to a functioning state. In that event it would not be in Mrs X’s interests to attempt CPR as it would only increase her suffering at the end of her life and not extend it any further. We appreciate Mr X and his father wanted every effort to be made to save Mrs X, and his father felt he should be consulted, but the guidance is clear.
20. The DNACPR appears to have been put in place fully in line with established guidance. In all likelihood, if one had not been put in place and CPR attempted, Mrs X would have still died, but the opportunity to make her final moments as comfortable and dignified as possible lost. This would not have been in her best interests.
21. Bearing in mind that this is a clinical decision only, justifiably made, and the requirement would be to inform the patient (or family in this case) of that decision once it has been made, we are not seeing any indication of the DNACPR being put in place too early or inappropriately.
Staff did not do enough to help his mother recover from and avoid a reinfection of pneumonia 22. Mr X is unhappy that his mother may have contracted pneumonia while an inpatient and says his mother should have been kept apart from other patients who could infect her.
23. Mrs X’s clinical notes show an admission due to blood clots her lungs (PE) and a suspicion of possible pneumonia. Maximum treatment to support her breathing and fight any infection was provided from the outset. This included antibiotic therapy and oxygen. Despite this Mrs X’s oxygen requirement steadily increased over time and a respiratory infection gradually progressed.
24. While there was an initial improvement in her condition from 17 to 21 January, this was short lived and appears to be an initial improvement due to the extra care provided. Despite being on antibiotics, the records show Mrs X deteriorated further and developed confirmed pneumonia (thought to be hospital derived). Sadly, she continued to decline and died on 28 January.
25. Our adviser confirmed Mrs X’s care was in line with NICE CG191 and NG138 guidelines which cover the diagnosis and management of pneumonia and the treatment of this with antibiotics. These mandate that the recommended treatment for pneumonia is the provide oxygen therapy to support breathing while providing antibiotics to help clear any infection in the lungs. They said she received the correct treatment in line with the expected standards.
26. Our adviser explained that many elderly deaths involve pneumonia or heart failure as patients reaching the end of their lives are unable to resist acquiring infections and have little physical reserves to fight them off. Respiratory infections are therefore often common occurrences when a person approaches the end-of-life stage coinciding with a loss of remaining resilience and resistance to succumbing to illness.
27. Mrs X was already receiving the appropriate treatment before reacquiring pneumonia (if this was not already present upon admission) and still deteriorated. Our adviser says this meant there was medically nothing more that could have been done for her than was already being done.
28. Antibiotics would usually provide some preventative protection from infection/reinfection in a patient not burdened with significant health problems, but we recognise Mrs X had multiple comorbidities, such as chronic PE, and an enlarged heart. If this precaution still did not stop pneumonia progressing, there would be no other method available to prevent the infection spreading.
29. We must conclude that there is no indication more could have been done to prevent infection or reinfection as the relevant guidance was followed and there were no other avenues to explore to help Mrs X survive her illness.
staff failed to manage his mother’s nutrition adequately
30. Mr Hone complained that his mother’s nutritional needs were not met. He says she was not eating or drinking enough, and the Trust took too long to attempt feeding by tube and supplement drinks.
31. The Trust says it supported Mrs X’s nutritional needs with various food options and encouragement to try and get her to eat more, but her intake was poor. It explains that initially tube feeding was not attempted due to the likelihood of this not working. Then later, when it was attempted, this proved to be the case as she could not tolerate it. It says that following this a referral to a dietician was made and Fortisips supplement drinks were prescribed. The Trust says it accepts the referral could have been made earlier.
32. As there is not dispute over there being a delay in providing Fortisips, we considered what the impact of this may be. Our adviser explained that ongoing hydration and nutrition have no established role in outcomes for patients as ill as Mrs X. They said that the main benefit of food provision would be for the comfort of the patient in this scenario. The slight delay in prescribing Fortisips would have no impact, especially during end-of-life phase, as Mrs X’s admission was short (just over a week) and she died from a respiratory infection. She also was still capable eating of, but would not eat much as her appetite had diminished.
33. We have not seen a lack of appropriate nutritional management here. The records indicate Mrs X was eating and drinking less because she was very ill and struggling to breathe, not due to being unable to. There was no physical impairment to her eating and drinking. She was encouraged to eat but did not want to. The initial assessment that a feeding tube would not be tolerated was correct, as this was trialed and not tolerated.
34. Our clinical advice indicates earlier provision of Fortisips would not have made the situation better. Mrs X’s intake would still have been poor and not altered her outcome even if she had taken on more nutrition via those drinks.
35. We have not seen any indication of inadequate support for Mrs X’s nutritional needs as tube feeding was not possible, and she had stopped eating due to her critical illness, so supplements would be of little benefit in making her feel better.
Staff failed to keep his mother’s IV drip working due to repeated drip bag splits.
36. Mr X is unhappy that there was a delay in having a replacement drip prepared when his mother’s current one was running low, and that there were two split bags later which also contributed to his mother having a pause in her IV fluids. The Trust says the nurses needed to wait for another prescription to put up another fluid bag and apologises if there was a delay in fluids due to bags splitting but they do sometimes get damaged.
37. Our adviser said ongoing hydration and nutrition have no role in outcomes for patients as ill as Mrs X. IV fluids would be provided for comfort to keep a patient hydrated. IV fluids would not need to be continuous to achieve this. Our adviser explains the pause due to awaiting another prescription and bag splits would not be long enough for Mrs X to become dehydrated. They reviewed her records and confirmed she also did not display any clinical signs of dehydration.
38. We recognise that Mr X may have understood that fluids needed to be continuously provided in order to help his mother, or that they were required to deliver her antibiotics. This would not be the case. The fluids would be provided only to provide hydration because his mother was no longer was drinking enough. The drip would not contain antibiotic doses as the bag contained only saline fluid and so this had no impact on her antibiotics being delivered into her body.
39. We have not seen an indication of a failing here, as what happened was on balance of probability, an unfortunate equipment failure and not a deliberate act. It would not be possible for us to establish intent with the available evidence in any event. What we can say is the pause had no impact on Mrs X’s outcome as she died from a respiratory infection and was not dehydrated.
Staff failed to take appropriate action when his mother started to deteriorate and show signs of sepsis.
40. Mr Hone says the Trust should have placed his mother on life support and done more when his mother deteriorated. As stated above, there was a (correct) DNACPR in place, based on the futility of attempting this, and she was receiving maximal treatment already for the cause of that deterioration there is nothing more that could have been done to prevent this than had been done already.
41. Sepsis is a complication of serious infection and NICE NG 51 guidance sets out the prescribed treatment for this would be fluids and antibiotics, which Mrs X had already been receiving for over a week in addition to oxygen support for her breathing. Our adviser confirmed that, if an infection continues to progress to sepsis despite these measures being in place, there would be no further options left to try.
42. It seems Mrs X died despite all efforts to prevent this. We appreciate that Mr X may have considered placing his mother on life support would have extended her life and helped her recover. This would not prevent her death from a spreading infection as mechanical ventilation would not affect this process. life support would not prevent respiratory failure from an infection that continued to spread and overwhelm the patient, only keep the lungs aerated.
43. Our adviser confirmed that attempting CPR would have been futile as it would not have worked. Placing Mrs X on life support would also have been futile as it would not have worked. The reason for this is neither would prevent death due to spreading infection and respiratory failure.
44. We must conclude that Mrs X continued to deteriorate despite maximal treatment, so either of these actions would not prolong her life and only increase her suffering. Similarly, as she was already the mandated treatment set out in the professional guidance for treating pneumonia and sepsis already, there was nothing additional that could have been done to prevent her continuing to deteriorate, as all medical options had been exhausted.
45. We accept that Mr X suspected that doctors gave up and allowed his mother to die. However, the indications are there were no actions that could have been tried that had not already been put in place. The documented discussion outlined earlier in this statement, where doctors told Mr X that they had not given up on Mrs X but sadly could not prevent her death, looks to be an accurate and responsible communication of the situation.
46. We are not seeing indications that Mrs X’s death was preventable as all practical medical actions were taken to support life. She died despite these being in place.
47. Overall, we have not seen indications of any failings in care in this complaint warranting further investigation. Mrs X appears to have been quite frail and suffering under the burden of multiple health problems before she was admitted to hospital due to chronic PE and suspected pneumonia.
48. That she later was confirmed to have pneumonia (home or hospital acquired) and then died despite all efforts to give her the best chance of recovery looks to be due to her failing health and not any clinical failing. It is understandable that Mr X would hope more could be done for his mother and feel it was not. The available evidence suggest it is likely that Mrs X had unfortunately reached the natural end-of-life phase which medicine could not prevent with the tools available.