AKI
16. The Trust has said when it discharged Mrs R in March her kidney function was stable and improving. It explained she had suffered from a mild deterioration of her kidney function caused by the cancer, but it had stabilised prior to discharge.
17. The Trust said it did not provide appropriate fluid management to Mrs R in the eight days prior to her death when the blood results showed she had an AKI. The Trust has said abnormal blood results on admission were not acted on, communicated or escalated which led to a delay in treating an AKI.
18. We have looked at Mrs R’s medical records from both admissions.
19. In the first admission Mrs R’s creatinine was 122. Creatinine is used to measure kidney function. The higher the reading the worse the kidney function. Our adviser explained that a normal range for women is 45-85. Our adviser also explained that estimated Glomerular Filtration Rate (eGFR) is used to estimate kidney function. The lower the eGFR the worse the kidney function, eGFR roughly corresponds to the percentage the kidney is working (i.e. 100 would means it is working at 100%).
20. The records show between 2017 and 2018 Mrs R’s eGFR was between 55 and 60 and the creatinine was around 100. This is likely to be her baseline, although our adviser said it is likely her baseline would have worsened over time due to her medical conditions.
21. NHS choices on CKD outlines eGFR results as a stage from 1 of 5:
• stage 1 (G1) – a normal eGFR above 90ml/min, but other tests have detected signs of kidney damage • stage 2 (G2) – a slightly reduced eGFR of 60 to 89ml/min, with other signs of kidney damage • stage 3a (G3a) – an eGFR of 45 to 59ml/min • stage 3b (G3b) – an eGFR of 30 to 44ml/min • stage 4 (G4) – an eGFR of 15 to 29ml/min • stage 5 (G5) – an eGFR below 15ml/min, meaning the kidneys have lost almost all of their function.
22. Our adviser explained in this period, Mrs R had stage 3a CDK.
23. When Mrs R was admitted to hospital on 28 January her creatinine was 122, with her baseline being 100. However, our adviser said it was not so bad that it would be classed as an AKI.
24. NICE guidance 148 says a diagnosis of AKI may be made if there is one of the following:
25. a rise in serum creatinine of 26 micromol/L or greater within 48 hours 26. a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days 27. a fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours.
28. In January Mrs R was admitted to hospital with a bowel obstruction which required emergency surgery. Our physician advice explained that some worsening of kidney function in this context is expected. They explained Mrs R was managed appropriately with intravenous fluids and was looked after in the intensive care unit (ICU) after her surgery. They explained her kidneys and other organs were monitored and supported closely.
29. On 1 February Mrs R’s kidney function deteriorated and our physician adviser said the Trust continued to monitor this. On 6 February her creatinine was 106, which is back to her baseline. The records show the surgical team continued to check the blood tests on a daily basis.
30. On 20 February Mrs R’s creatinine was 114, her sodium and potassium levels were also outside of the normal range. The medical team sought advice from endocrinologist.
31. The endocrinologist treated the sodium and potassium levels. The endocrinologist thought Mrs R was losing water/fluid for a number of reasons. They thought the loss was through high output stoma, high calcium levels and nephrogenic diabetes insipidus. This is when the kidneys do not respond to a hormone called vasopressin as it should. It means too much fluid gets flushed out in the urine. The team identified the high calcium levels and the nephrogenic diabetes insipidus were side effects of a medication (lithium) Mrs R was taking for bipolar affective disorder.
32. The endocrinologist advised the lithium should be stopped and asked the psychiatry team to advise about alternatives. Mrs R continued to have daily blood tests, and her kidney function was closely monitored. On discharge, her creatinine was 125.
33. Our physician adviser said Mrs R’s kidney function was closely monitored during the admission and when it deteriorated it was treated and expert guidance was sought. They explained there were a number of complex reasons why her kidney function was worsening and the Trust treated her appropriately.
34. Through our work we have not seen evidence Mrs R had an AKI as described by NICE guidance 148 in the first admission. While we have seen evidence of worsening kidney function during the admission, we consider the Trust appropriately monitored and cared for her. As such we will not be taking further action here.
35. We next looked at the second admission on 16 April 2023. When Mrs R was admitted to hospital her creatinine was 186. Our adviser explained if we take the baseline to be 125 (her creatinine level at the end of the previous admission), it would make this a borderline AKI as there is a 49% rise. If we take the baseline as 100 then this is an AKI as this would indicate an 86% rise.
36. Our adviser said the creatinine level has been documented in the records but not the significance of this. They also highlighted a gap in blood tests between 16 April until 21 April. The next blood test documented is 24 April by which time Mrs R’s creatinine had risen to 367. At this point it was understood that Mrs R was near the end of her life and a palliative care approach was taken. On 27 April the end of life care plan was started.
37. Our adviser explained that worsening kidney function represents the dying process from cancer. They explained it occurred as a consequence of her illness rather than being the cause of her deterioration. Our adviser explained that at this point Mrs R was very sadly dying and her organs were shutting down. They explained the AKI could have been spotted earlier and this would have meant the dying process would have been diagnosed more quickly. However, we have not seen this would have made a difference to the overall care the Trust provided to Mrs R or her prognosis.
38. Mr R has told us the AKI went untreated for too long so that by the time it was diagnosed she was too unwell to recover. We understand why he has this view and how distressing it must have been to know the AKI could have been diagnosed sooner. Taking into account the evidence we have seen, we have not seen indications Mrs R had an AKI during the first admission. We have seen indications she had an AKI (or borderline AKI) on her second admission, however this was as a result of the progression of her cancer. We have not seen indication it was the cause of her deterioration. For these reasons, we will not be taking further action here.
Bipolar medication
39. The Trust said the psychiatrist stopped Mrs R’s lithium on 27 February at 1.43pm. The psychiatrist prescribed quetiapine and advised it should be gradually increased to 200mg twice daily until 2 March 2023. The advice was to observe Mrs R’s mood and level of consciousness as quetiapine can have a sedative effect. The Trust reviewed her medication again on 6 March and decided she should remain on quetiapine. Quetiapine is medication used to help with mental health conditions such as bipolar disorder.
40. GMC guidance says that when treating patients, doctors must adequately assess the patient’s conditions, taking account of their history and where necessary examine the patient.
41. We have looked at Mrs R’s medical records. We can see the Trust changed her medication because it was affecting her kidney function and calcium levels. The endocrinologist advised the staff stop lithium and to discuss this with a psychiatrist to find an alternative. We note the psychiatrist works for another Trust which does not form part of this complaint, but they recommended quetiapine be administered. The psychiatrist said quetiapine can cause drowsiness and this should be monitored.
42. The records say the psychiatrist was due to review Mrs R on 2 March. However, there is no record of this review taking place. On 2 March the notes say she is ‘still feeling confused’, and on 5 March she is feeling sleepy. Our adviser said a re-referral to psychiatry would have been appropriate as the planned review did not take place.
43. Taking into account the evidence, we have seen indications the Trust did not appropriately monitor Mrs R when it changed her medication, and this was not in line with GMC guidance.
44. Mr R tell us his wife was very drowsy when her medication was changed. He tells us how distressing this was to witness and concerning that the Trust were not monitoring it.
45. Our physician adviser said the impact on Mrs R is she would have suffered from drowsiness, and this could have been addressed. They explained it is also likely the multiple other medical problems she was suffering from caused delirium which can also lead to drowsiness. However, the medication should have been reviewed as it is possible this could have been changed.
46. As part of our work, we approached to the Trust to see if it would resolve this matter for Mr R. The Trust has provided a further response on this. It said the medical team documented a discussion with the psychiatry specialist doctor on 27 February about Mrs R’s medication. It said the plan was to stop the lithium and to increase quetiapine with a further review on 2 March. The Trust has apologised this review did not take place. The Trust said there was a further review by the psychiatry team on 6 March where they noted Mrs R was stable after the medication was changed.
47. Taking into account the evidence we have seen, we find the Trust’s action to apologise and explain what happened sufficiently remedies the complaint for Mr R. We know how concerned he was about his wife’s medication and that she was not reviewed sufficiently when it was changed. We have seen she was reviewed four days later, and it was recorded that she was stable.
48. Our Complaint Standards say organisations should give a ‘clear, balanced account of what happened based on established facts’. When things go wrong, they should ‘identify suitable ways to put things right for people’. They should give ‘meaningful and since apologies and explanations’.
49. While we acknowledge Mr R’s concerns, in line with our Complaint Standards, we find an apology is an appropriate remedy here and will not be taking further action.
Confusion
50. The Trust said when Mrs R was discharged from hospital on 27 March 2023 it was documented she was alert and orientated. It said there was no documented evidence that she was confused at the time.
51. NICE guidance 103 recommends clinicians assess all people in hospital over the age of 65 for delirium.
52. We have reviewed the medical records and cannot see evidence the Trust formally assessed Mrs R’s cognition when she was admitted to hospital on 27 January.
53. We can see from the medical records there are several points in the notes where the nurses have commented Mrs R is alert and not confused. We can see on 20 February Mr R raised concerns with the dietician about Mrs R’s confusion and suggested the Trust should carry out a confusion screen. On 2 March the notes say that she is ‘still feeling confused’.
54. As part of our work, we asked the Trust whether it formally assessed Mrs R’s cognition. It said a confusion screen was requested on 21 February and was completed. It said it included blood and urine testing. The Trust apologised it missed the opportunity to formally assess Mrs R’s condition when she was admitted. It said doctors did not think this would have changed the treatment plan for Mrs R during her admission.
55. We have seen indications the Trust should have completed an assessment of Mrs R’s cognition on admission. Our physician adviser did note the Trust monitored Mrs R’s blood tests closely and they would have revealed any sign of infection which can be a cause of confusion. However, she had several risk factors for developing delirium such as recovery from surgery, a prolonged hospital stay, abnormal electrolyte levels and a change in psychiatric medication. We do not consider the Trust’s actions were in line with NICE guidance 103, and this is an indication of a failing.
56. Our adviser explained Mrs R’s medical problems were being dealt with and we have previously addressed the change in medication. We accept it would have been helpful for Mrs R and her family to have this explained as they were concerned about her confusion. We did not find the formal cognition screening would have changed the Trust’s approach to her care and treatment.
57. Mr R has told knowing his wife did not receive the care she had the right to receive has caused him and his family deep distress. We hope our explanation of why we do not think the lack of a formal cognition screening impacted the care his wife received brings some reassurance.
58. We have seen the Trust has apologised for not completing the screening when it admitted Mrs R. We find this to be a suitable remedy and in line with our Complaint Standards.
59. The Trust said the nursing notes show Mrs R’s pressure areas were all intact when she arrived at the surgical assessment unit (SAU) in January. It is documented she had an area on her bottom which was thought to be a healing moisture lesion.
60. On 28 January nursing staff washed her, and they documented she had a non- blanching purple area on her bottom, in line with what was reported in the SAU. The team ordered a pressure relieving mattress for her.
61. On 29 January a nurse assessed Mrs R’s pressure areas, and they thought she had a possible deep tissue injury. An adverse incident was entered on to the Trust’s reporting system and a referral to the Tissue Viability Nurse (TVN) was made.
62. Mrs R was seen by the TVN on 30 January. The TVN requested two hourly repositioning and the use of an appropriate mattress.
63. Our nurse adviser said Mrs R was commenced on daily nursing interventions in-line with a pressure ulcer prevention plan on the 28 January. This was part of the care rounding bundle and incorporated skin inspection, positioning, continence and nutrition information. While we can see an occasional record was incomplete, the care plans were largely completed consistently.
64. The Trust said it is difficult to know when the ulcer developed. It said from the records it appears that when she was discharged on 27 March, her skin was intact.
65. The Trust said when Mrs R was readmitted, she was seen by the TVN on 17 April. The TVN documented a large necrotic pressure ulcer, and the plan was for the dead skin to be removed that day.
66. NICE guidance 179 says that all patients are potentially at risk of developing a pressure ulcer, however they are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or poor posture or a deformity.
It recommends clinicians prioritise risk assessments, skin assessments, care planning, repositioning, and devices for the prevention of pressure ulcers.
67. Our nurse adviser said all of the above recommendations were adhered to by the Trust and are documented in the nursing records.
68. We can see Mrs R was risk assessed on both admissions to the Trust. The Trust used a Waterlow risk assessment, this is a validated risk assessment tool used to calculate the risk of someone developing a pressure ulcer and is in line with NICE guidance 179.
69. We can see from the records that on the first admission the Trust only partially completed the Waterlow score and on the second admission the assessment was inaccurate which led to a score of 14 rather than 21. Our adviser said this occurred because it did not record that Mrs R had a neurological condition and stated that she had a grade 1 pressure ulcer, when it is recorded elsewhere in the medical records that she had a 6cm necrotic sacral ulcer, a grade 4 pressure ulcer. This is an indication of failing.
70. The Trust said it recognised while this will bring Mr R anxiety and distress, it could assure Mr R this had limited impact on Mrs R’s care. Our nurse adviser said the errors would have had little impact on the care Mrs R received. We do accept that knowing there were errors in the documentation would have caused Mr R distress.
71. As part of our work, we asked the Trust about this matter. It agreed the Waterlow score had been inaccurately recorded. It offered it sincere apologies there was an error in the Waterlow score being documented. It said it is moving away from using Waterlow scoring method to a new assessment tool. It said it is confident this will support more robust scoring and management for preventing pressure ulcer development in patients in the future. We consider the Trust has appropriately addressed what happened, in-line with our Complaint Standards.
72. We do not underestimate how concerning it was for Mr R to know his wife had a pressure ulcer and that he thinks this was caused by poor care. We have not seen evidence to support this view. Our physician adviser further explained that sadly Mrs R was dying, and the breakdown of her skin was part of the dying process. They explained the breakdown of her skin was not the cause of her deterioration. We will not be taking further action here.
73. We have seen evidence in the records that medical staff struggled at times to obtain blood from Mrs R. We can see from the notes that on 19 February the nursing team had been unsuccessful in getting blood samples and a doctor had also tried twice and failed. We can see the following day the Trust referred Mrs R to the vascular access team to gain intravenous (IV) access which could be used for infusions and obtaining blood.
74. NMC guidance says nurses must respect the skills, expertise and contributions of [their] colleagues, referring matters to them when appropriate.
75. The team reviewed Mrs R and she declined to let them get IV access until her husband was there later that day. Once Mr R had arrived, the ward doctor attempted to get IV access and failed. Mrs R did not consent to any more attempts. Our nurse adviser explained the vascular access team were the correct team in this circumstance. We have not seen indications of failings in the actions of the nursing team, and consider the appropriate referrals were made.
SALT referral
76. The Trust said the SALT referral was delayed and the ward team did not record that Mrs R was nil-by-mouth on the referral which means it was not picked up.
77. The Trust said this was fed back to the ward team to ensure that learning has taken place and that all patient’s feeding statuses are discussed at the daily safety huddles to ensure that patients do not go a prolonged period of time without nutrition.
78. GMC guidance says clinicians must contribute to the safe transfer of patients between healthcare providers. This means they must share all relevant information with colleagues involved in patients’ care within and outside the team.
79. Our physician adviser said there is no specific guidance for how quickly a patient should be seen by SALT in hospital, however NICE guidance 32 says patients who are nil by mouth for longer than five days are at risk of malnutrition.
80. We have not seen evidence the referral to the SALT team was delayed as it was made one the Trust had identified she required extra support. We have seen the Trust did not share all the relevant information with the SALT team about Mrs R’s feeding status when it made the referral. This meant the SALT team did not pick up the referral in a timely manner. We find this to be an indication of a failing.
81. We can see from the SALT assessment the therapist commented that Mrs R’s swallow had fatigued due to a prolonged period of being nil by mouth as well as her multiple sclerosis and pain. The records say her swallow eventually returned to normal and no dietary modifications were required on discharge.
82. Our physician adviser said that once Mrs R had input from the dietician, the relevant specialists closely monitored her nutrition. They said there is no evidence of long term harm being caused by the delay in being seen by SALT. However, we understand this was likely an unpleasant experience for Mrs R and a great cause of concern for Mr R.
83. As part of our work, we raised this matter with the Trust. It acknowledged and apologised for the delay in SALT assessing her. It has accepted it would have been distressing and uncomfortable for Mrs R to have been nil by mouth for this period. It has offered Mr R a financial remedy of £500 in recognition of this distress this caused.
84. We consider the Trust has acknowledged the failings, apologised, made service improvements and offered Mr R a financial remedy. We find this to be a suitable remedy for the impact he has faced in line with our Complaint Standards.
Hospice referral 85. GMC guidance says clinicians must refer patients to another practitioner when it serves the patient’s needs.
86. The Trust said the palliative care consultant reviewed Mrs R on 27 April and requested a referral be made to the hospice. A referral was started but as Mrs R’s prognosis was documented as being less than six weeks, the provider would not accept her. The provider said it only accepts patients with a prognosis of less than two weeks.
87. The Trust said a second referral was made to another provider on 29 April. This hospice required further information which caused a delay in the referral. The Trust said it sent the referral on 3 May and it has apologised for the delay. It explained the delay was caused because it was over a bank holiday.
88. When we raised this with the Trust as part of our work, the Trust apologised for the delay and it explained it now ensures bank holiday weekends are now resourced differently to ensure discharge planning is seamless over long weekends.
89. Mr R has told us how distressing it was to know the palliative care referral was delayed and that this meant when the referral was made, his wife was too unwell to be transferred. We are sorry to hear how this affected them. We have seen the Trust has apologised and made service changes to help avoid similar occurrences in the future, this is in line with our Complaint Standards. For this reason, we will not be taking further action here.
90. The Trust has said on 1 May the surgical consultant reviewed Mrs R’s wound and noticed some necrotic skin. The surgical registrar attended and removed the necrotic skin and redressed the wound. The Trust said the records indicate verbal consent was obtained. It goes on to say that while Mrs R would not have been able to give consent at that time, the surgical registrar would have still informed her of what was going to happen.
91. The Trust said the procedure was completed in Mrs R’s best interest. It did this with the intention of keeping her comfortable as dead skin can often cause pain and discomfort.
92. GMC guidance says in providing clinical care clinicians must prescribe drugs or treatment when they are satisfied that the drugs or treatment serves the patient’s needs. It says they must take all possible steps to alleviate pain and distress whether or not a cure may be possible.
93. Our physician adviser explained the removal of the skin was a minor procedure that is not likely to be painful. They explained the procedure would not need anaesthetic and is unlikely to have caused distress. We hope this helps to reassure Mr R.
94. We have reviewed Mrs R’s medical records from 1 May 2023 at 9.19am. The records say, ‘patient’s pressure sore examined- no collection, no cellulitis, necrotic skin well demarcated’. A plan is made to complete a minimally invasive procedure to remove the necrotic tissue.
95. Later that day at 1.20pm a surgical registrar attended to Mrs R to remove the dead tissue. The records say, ‘verbal consent obtained’, following the procedure the records say, ‘site redressed...patient comfortable after procedure’.
96. Mr R has told us the Trust could not have sought consent from his wife as she was not responsive at this time and therefore could not have given verbal consent.
97. We have looked at other entries in the medical records to help us reach a view on what happened here. We can see on 29 April the nursing notes say Mrs R is ‘alert and drowsy’. On 30 April the records say Mrs R was comfortable but does not comment on whether she was alert or responsive.
98. On 1 May at 2pm (after the procedure) the records say, ‘patient is awake’.
99. We have seen evidence the procedure was minimally invasive and while both the Trust and Mr R confirm it is unlikely Mrs R would have been able to provide consent at this point, we have not seen evidence the procedure would have hurt her or caused her distress. The Trust has said the procedure was done in Mrs R’s best interest and we consider this is in line with GMC guidance.
100. We understand how concerned Mr R is that this procedure caused his wife unnecessary pain. We hope our explanation and the advice we have received will give some assurance that the procedure is unlikely to have caused her any pain.
High stoma output 101. We can see there are multiple references in the notes which refer to high stoma output. High stoma output is a stoma that produces too much fluid over 24 hour period. According to Trust guidance on the management of adult patients with a high stoma output, patients are considered to have high stoma output if their stoma output is more than 1.5 to 2 litres in 24 hours for three or more consecutive days.
102. On the Trust’s discharge letter following Mrs R’s first admission it says she had high stoma output and this was treated with loperamide. This is a medication used to treat diarrhoea, it is also used to treat a high stoma output. It goes on to say that Mrs R underwent a laparotomy with bowel resection (surgery to remove a small part of the bowel) on 28 January and had a high stoma output since the procedure.
103. The Trust’s guidance explains the treatment plan for high stoma output should include:
• prescribing Hartmann’s intravenously (this is used to replace the body’s fluids) • considering restricting other oral fluids such as water, milk or other soft drinks including tea and coffee • encouraging patients to eat normally if they can • starting an electrolyte replacement solution • monitoring patients’ urea’s and electrolytes, magnesium, calcium and phosphate levels • keeping daily patient weight • keeping accurate fluid balance charts and measuring urine output.
104. Our physician adviser explained high stoma output can lead to poor absorption of nutrients, salts and fluids which can lead to dehydration and weight loss. They said the surgical team with input from dieticians, managed the high stoma output in line with the Trust’s local guidance.
105. Our physician adviser highlighted the stoma output did slow down with management in the first admission. They explained from the records it appears it was challenging for the Trust to manage Mrs R’s high stoma output, however the treatment was appropriately managed and in line with the Trust’s guidance.
106. In the second admission we can only see evidence of one reference to stoma output where the stoma nurse records the output to be good.
107. Our physician adviser explained based on the evidence they reviewed that high stoma output was one of the factors that caused Mrs R to decline, but ultimately her death was caused by cancer.
108. We understand why Mr R is concerned that high stoma output was listed as a cause of death.
109. The Trust listed Mrs R’s cause of death as:
• acute kidney injury • high stoma output • neuroendocrine tumour of the bowel and frailty
110. Department of health and social care guidance explains that when documenting a person’s cause of death, clinicians should first list the immediate, direct cause of death. Then they should go back through the sequence of events or conditions that led to the death until they reach the condition that started the fatal sequence. We consider this explains why the Trust appropriately included this condition as a contributing cause of death.
111. We understand Mr R does not believe a high stoma output contributed to his wife’s death. We have seen evidence in the records that Mrs R did have a high stoma output, and that the Trust appropriately managed this. Our adviser also explained this high stoma output was a contributing factor in Mrs R’s death. We hope this helps to answer his concerns about this matter.