The Trust’s response to Mr Q’s deterioration
23. In her complaint to the Trust, Miss Q said she visited Mr Q in hospital around 6pm on 9 February 2023. After waking him up, she said Mr Q was confused, he slurred his speech, and he could not articulate his words. She said he could not raise both his hands. She added staff had inserted a breathing tube, and his breathing was shallow and fast.
24. She said she raised these concerns with nurses as she felt something was wrong, and Mr Q displayed signs of a stroke. However, these nurses did not act on this, and they considered he was stable.
25. Around seven hours later, after she had gone home, Miss Q said staff called her to explain Mr Q’s lung had collapsed and he was deteriorating rapidly. She considered staff should have acted on the signs of deterioration she saw, but they failed to.
26. The Trust’s investigations into Mr Q’s care said he was stable during the day, albeit while on supplemental oxygen. During the night, he suffered a sudden reduction in his oxygen saturation levels, which staff responded to.
27. Staff found, through an X-ray, his lung collapsed suddenly. The Trust considered it likely food or mucous had blocked Mr Q’s airway and caused his lung to collapse.
28. The Trust said its staff considered treatment, for example, organ support in the intensive care unit. However, given Mr Q’s frailty and poor general health, staff decided against this treatment. They considered this would not help him recover and he would die.
29. Following careful consideration, we saw staff acted in line with guidelines on this matter.
30. Our physician explained staff used NEWS to monitor Mr Q’s condition. NEWS is a recognised scoring system staff can use to standardise the assessment of patients and their response to acute illness.
31. The RCOP Guidance explains most NHS hospitals use NEWS. It also sets out how staff should use NEWS.
32. NEWS assess a patient’s breathing rate, oxygen saturation level, blood pressure, heart rate, level of consciousness, and temperature. Staff give each parameter a score between zero and three. A score of zero means the parameter is normal. Higher scores indicate the patient is more unwell.
33. Staff add up scores for each parameter to give a total score. They should add two to this score if they need to give a patient supplemental oxygen. A higher overall score means the patient is more unwell and at higher risk of deterioration. The RCOP Guidance says NEWS of one to four is a low score. NEWS of seven or more is a high score.
34. Depending on the scores, section seven in the RCOP Guidance explains the thresholds which should trigger certain responses from staff, and how often they repeat their NEWS observations.
35. If staff record a patient’s NEWS at zero, staff should repeat NEWS observations every 12 hours.
36. If their NEWS rise to between one and four, staff should inform a registered nurse, who must assess the patient. They decide whether staff need to increase the frequency at which they check a patient’s NEWS, and whether they need to escalate a patient’s care. At a minimum, staff should recheck a patient’s NEWS every four to six hours.
37. If a patient scores a three in any single parameter, a registered nurse must inform the medical team caring for the patient. These staff will review the patient and decide whether they need to escalate the patient’s care. Staff should recheck a patient’s NEWS at least every hour.
38. If a patient’s NEWS rise to five or more, the registered nurse must inform the medical team caring for the patient immediately. They should ask for a clinician with core competencies in the care of acutely ill patients to do an urgent assessment on the patient. Staff should recheck a patient’s NEWS at least every hour.
39. If a patient’s NEWS rise to seven or more, the registered nurse must inform the medical team caring for the patient immediately. They should inform a member of staff from the team at least at specialist registrar level.
40. They should request an emergency assessment by a team with critical care competencies. This team should consider whether to transfer the patient’s care to a higher dependency or intensive care unit. Staff should continuously monitor a patient’s NEWS in a care environment with monitoring facilities.
41. Our physician said the NEWS staff recorded indicated Mr Q was unwell but stable until late in the evening on 9 February. They added he had an existing plan in place to support his breathing. Staff had been giving him supplemental oxygen through a nasal cannula to manage his oxygen saturation levels. These factors meant Mr Q generated NEWS.
42. During the evening of 8 February, we saw staff recorded NEWS of three in Mr Q’s records. They recorded a score of one for his oxygen saturation level (95%). They added two because they were giving him oxygen through the nasal cannula. His nursing records show staff increased the flow rate to four litres of oxygen per minute around 6am on 9 February, up from one litre.
43. During the ward round he had with a consultant at 10.05am on 9 February, Mr Q’s NEWS remained unchanged at three. We saw he had a score of one for his oxygen saturation level (94%) and he remained on supplemental oxygen. The consultant noted he appeared comfortable, and his chest was clear.
44. Our physician said the consultant planned to continue his current care arrangements. Our physician did not see his observations indicated he would deteriorate or there was further care the consultant needed to plan for any deterioration.
45. We saw Mr Q’s care records show his NEWS remained at scores the RCOP Guidance deems low throughout the day and into to the evening of 9 February. This included identical NEWS of three at 6.14pm and 8.52pm. Staff checked his NEWS again at 9.07pm and they recorded a score of two. This was because Mr Q’s oxygen saturation level improved to 97%.
46. We recognise the score at 6.14pm coincides with the time Miss Q said she saw Mr Q, and she felt he looked very unwell. We consider his NEWS are a more reliable measure about this, and whether Mr Q was deteriorating at the time.
47. This is because p is a recognised and standardised system which records specific measures to assess illness severity and any deterioration. These measures are inputted by clinical staff trained to use the system, who were recording this information throughout Mr Q’s admission.
48. Mr Q’s NEWS show stability at the time, albeit while our physician said he was unwell. His NEWS also recorded information we appreciate Miss Q mentioned. She referred to Mr Q having breathing equipment in place to support his breathing. This appears to be the supplemental oxygen staff recorded they were giving him within his NEWS documentation.
49. As we consider the documentary evidence is a more compelling source about Mr Q’s condition, and our physician said he was stable at the time, we did not see his condition was deteriorating at the time Miss Q saw him.
50. As was already their plan, staff were continuing to recheck his NEWS within the frequencies the RCOP Guidance recommends for patients with NEWS between one and four (every four to six hours). Staff continued with the care arrangements set by the consultant overseeing Mr Q’s care. This is in line with the RCOP Guidance, and we did not see staff should have escalated his care in response to any deterioration.
51. The evidence in Mr Q’s records, including his NEWS, show he deteriorated later.
52. Following their check at 9.07pm, nursing staff repeated Mr Q’s NEWS at 11.15pm. They noted his oxygen saturation level had fallen to 83%. This meant he scored three in this parameter, while on supplemental oxygen. This meant his NEWS rose to five.
53. In line with the RCOP Guidance, nursing staff escalated his care and requested that a doctor review him urgently. The doctor saw Mr Q at 11.20pm. They asked nursing staff to reposition him and check his NEWS again after doing so.
54. In line with the steps from the RCOP Guidance we described in paragraph 38, we saw staff checked his NEWS again within one hour at 11.50pm. They recorded his oxygen saturation level remained at 83% and total NEWS of five. Nurses contacted the doctor again.
55. Over the phone, the doctor instructed staff to escalate Mr Q’s oxygen treatment in advance of them coming to review him. They asked staff to replace his nasal cannula with a venturi mask delivering 35% oxygen at a flow rate of eight litres per minute. Despite this, Mr Q’s oxygen saturation level dropped further to 80%.
56. The doctor then advised staff to connect him to a non-rebreather mask with a flow rate of 15 litres of oxygen per minute. Our physician this said is a type of mask which gives patients highflow oxygen.
57. We saw the doctor arrived to see Mr Q at 12.10am on 10 February. As they saw his oxygen saturation levels were not improving, they asked nurses to call peri-arrest team colleagues as an emergency. These colleagues arrived at 12.20am.
58. Our physician said what happened from 11.15pm was an abrupt deterioration in Mr Q’s condition, which staff then responded to promptly. His observations before this point did not indicate he would deteriorate like this.
59. We also saw, based on the NEWS staff recorded from this point, and the timings in which they escalated Mr Q’s care to senior clinicians and repeated his NEWS, they took the steps the RCOP Guidance recommends. This means, having considered the evidence and advice, we saw no failing in staff responding to Mr Q’s deterioration when this started.
60. When these more senior clinicians become involved, the RCOP Guidance says, through their assessments, they should consider whether to escalate the patient’s care. This includes whether they should transfer them to a higher dependency unit. We saw these staff did this.
61. Our physician said these staff needed to reach a decision on escalating care in line with the decision-making principles explained in Good Medical Practice. Section 16 in Good Medical Practice says, in providing clinical care, staff must:
• prescribe treatment only when they have adequate knowledge of the patient’s health and are satisfied the treatment serves the patient’s needs • provide treatments based on the best available evidence • consult colleagues where appropriate.
62. To investigate Mr Q’s sudden drop in his oxygen saturation levels, we saw the Trust’s doctors asked radiology colleagues to do an immediate X-ray. Doctors also did an ultrasound.
63. As we saw staff noted in his records, our physician said Mr Q’s X-ray showed a whiteout of his right lung. They said this is where the entire lung appears white in the X-ray image. Fluid around the lung or lung collapse can cause this finding. Noting this observation, we saw the Trust’s radiologists reported Mr Q’s X-ray suggested his lung had collapsed.
64. Our physician added his ultrasound showed no fluid around his lung. Therefore, this supported the evidence staff considered from both scans to conclude Mr Q’s lung collapsed.
65. Having gathered this evidence on what happened, staff then decided against escalating his care. They did not consider intensive care treatment was likely to help him recover, and he would die. On this basis, they planned end-of-life care and medications to try and aid his comfort.
66. In reaching this decision, we saw staff noted his breathing rate was decreasing, and he was finding it more difficult to breathe. His oxygen saturation level had fallen further to 72%. He was also losing consciousness. On this basis, they considered his lung collapse was likely to lead to his death and he was approaching the end of his life.
67. Staff also noted other conditions Mr Q had like his chronic kidney disease, and he was not likely to benefit from intensive treatments like filtration to help his kidney function.
68. Our physician said deciding to escalate a patient’s care to a higher dependency unit, including intensive care, is a difficult clinical judgement. Staff provide invasive and distressing interventions to try and give critically ill patients live-saving care. Many patients do not survive to go home. For those who do, they may continue to have serious health problems after this treatment and a poor quality of life.
69. Given the burdens of such treatments and the limited chances of survival even when patients receive them, our physician said such treatment will not be appropriate for every patient. Staff must decide whether the benefits outweigh the burdens, and whether endoflife care is in the best interests of a patient instead.
70. Our physician said a key factor clinicians should consider when reaching a judgement is whether there is at least a reasonable chance the patient will survive. If there is not, endoflife care is likely to be the more appropriate option for the patient.
71. In Mr Q’s case, our physician said the evidence staff obtained about his condition showed features they would expect to see in someone who is about to die. Therefore, the factors staff considered supported their approach not to escalate his treatment and provide endoflife care.
72. Having considered the evidence and advice, we saw staff followed the decision-making principles in Good Medical Practice in deciding what to do. A range of staff gathered suitable evidence to understand Mr Q’s condition. Based on that evidence, they reached a decision on what care and treatment served his needs.
73. As they reached this decision in the way Good Medical Practice recommends, and our physician saw factors supporting the decision staff made, we saw no failing in the action staff decided to take.
74. This means, in summary, we saw nurses promptly escalated the issue of Mr Q’s deterioration to senior clinical colleagues when this became evident. These colleagues then reached a decision about how to respond to this and how and whether to escalate his care in the way they should have. This resulted in them deciding to provide end-of-life care.
75. We appreciate why Miss Q has concerns about Mr Q’s care given how suddenly he deteriorated. We hope our findings provide her assurance about his standard of care, and this helps bring her closure on this matter.
Consultation about Mr Q’s DNACPR order
76. Miss Q told us the Trust had listed her and her sister as next of kin for Mr Q. She said they asked staff earlier in Mr Q’s admission to involve them in any decisions on his care.
77. Miss Q said staff discussed Mr Q’s DNACPR order with him and his wife. She said Mr Q was very unwell at the time. She added his wife has a learning disability, and she did not recall having a conversation about Mr Q’s DNACPR order. For these reasons, Miss Q felt staff should have discussed this matter with her and her sister.
78. The Trust, in its review of Mr Q’s care, and in its resolution meeting, said staff discussed Mr Q’s treatment escalation plan with him and his wife on 24 January. Staff explained, as he was frail and had multiple health problems, he would not survive a critical illness. After this conversation, the Trust said Mr Q and his wife understood this explanation and staff would not refer him to intensive care if he deteriorated or resuscitate him.
79. The Trust said, having had this conversation, it would not inform all family members about it. The Trust added staff were not aware Mr Q’s wife had learning difficulties until Miss Q told them later, and staff changed his next of kin details.
80. We saw staff acted in line with guidelines on this matter.
81. In his records, staff recorded Mr Q experienced confusion. On this basis, our physician said staff had reasons to consider he did not have capacity to contribute to a decision on resuscitation. Therefore, our physician said staff needed to adhere to relevant sections of the CPR Guidance and the End-of-Life Decisions Guidance. They both contain guidance on how staff should manage decisions about resuscitation in these circumstances.
82. The decision-making framework in the CPR Guidance says where a patient lacks capacity, staff should explain their decision not to perform resuscitation to those close to the patient without delay. Paragraph 136 in the End-of-Life Decisions Guidance contains similar instructions.
83. We saw Mr Q’s records corroborate the accounts of both Miss Q and the Trust that staff discussed his DNACPR order with him and his wife. This means we saw staff discussed Mr Q’s DNACPR order with someone close to him.
84. The guidelines we referred to in paragraphs 81 and 82 do not say staff should assess the capacity of the relative they discuss a DNACPR order with. That said, our physician would have expected staff not to have consulted that particular person if it was obvious they were unable to take part in and understand the discussion.
85. We saw the entry where staff recorded discussion about Mr Q’s DNACPR order also included discussions about his treatments. In the conversation, Mr Q’s wife queried why staff had stopped his aspirin and clopidogrel.
86. Staff told her they were withholding these medicines because they increased the risk of bleeding in his brain. Staff had found bleeding in the CT scan he had soon after he arrived in hospital following his fall at home where he hit his head.
87. Mr Q’s wife said she felt withholding these medicines was a risk as they were medications to manage his heart disease. However, she recognised providing them increased Mr Q’s risk of bleeding in the brain, and she appreciated the risks of giving him these medicines outweighed the benefits.
88. We consider this shows Mr Q’s wife could take part in the discussion. As she raised questions about Mr Q’s medications and formed opinions about omitting them after weighing conflicting risks and benefits, it indicates she understood the discussion at the time.
89. Our physician said, given the evidence of her taking part in and understanding the discussion, they would not have expected staff to assess her capacity.
90. Considering all this, we did not see reasons for staff to doubt whether Mr Q’s wife was a suitable relative with capacity to speak to on this matter. This means staff acted in line with the CPR Guidance and the End-of-Life Decisions Guidance in speaking to someone close to Mr Q about his DNACPR order at an early stage in his admission.
91. Our physician added the CPR Guidance and the End-of-Life Decisions Guidance does not say how many people staff should consult about a patient’s DNACPR order. Therefore, they would expect to see staff consult just one person close to the patient about this.
92. As we explained above, staff fulfilled this requirement when they spoke to Mr Q’s wife.
93. We recognise Miss Q wanted to be involved in discussions about Mr Q’s care, including on matters like his DNACPR order. On this basis, we recognise it must have been distressing for her to later find out staff already discussed and decided on a DNACPR order for Mr Q.
94. We hope we have clearly explained what we saw on this matter and why staff acted in line with guidelines.
When staff told Miss Q that Mr Q had died
95. In her complaint to the Trust, Miss Q said staff called her at 1.21am on 10 February. They explained Mr Q’s lung had collapsed, and they advised she should come to hospital. She said her family arrived on his ward around 2am. One of the nurses escorted her family to Mr Q’s bay on the ward. The nurse allowed Miss Q to pull open the closed curtain around his bay. When she did, she could see Mr Q had died.
96. Miss Q then asked the nurse to confirm whether he had died. She said the nurse confirmed he died quickly, and they were sorry. The nurse added he was alive when they called her. Miss Q told us it was unacceptable staff had not told her Mr Q had died before she opened the curtain.
97. After listening to Miss Q describe these events to staff in the resolution meeting the Trust held, it followed up in writing to apologise about the way Miss Q discovered Mr Q died. In the meeting, we saw the Trust said there was a gap in communication.
98. The Trust said Mr Q was alive when staff called Miss Q. He died while her family was on the way to hospital. Staff did not call her in the meantime because they do not normally tell someone their relative has died on the phone. However, staff failed to tell her family in person between their arrival on the ward and going to Mr Q’s bed.
99. We saw staff did not act in line with guidelines on this matter.
100. Section 33 in Good Medical Practice says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
101. Section 5.5 in the NMC Code contains similar wording for nurses. Nursing staff should share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand.
102. Our physician noted these guidelines do not say when staff should tell those close to a patient that person has died. However, the guidelines say staff should be sensitive towards relatives in sharing information like this. Given staff had told Miss Q’s family Mr Q was alive when they asked them to come to hospital, to act in line with this principle, our physician would have expected staff to tell them Mr Q died before showing them to his bed.
103. Having reviewed the evidence and advice, we saw staff could and should have handled this situation more sensitively by telling Miss Q’s family Mr Q had died before showing them to his bed. As staff did not do this, we saw they did not act in line with the principles we explained in paragraphs 100 to 102.
104. We saw this caused Miss Q’s family added and avoidable distress around the time of Mr Q’s death.
105. Based on the information her family got from staff, they expected to see Mr Q alive and spend time with him before he died. Staff could have prepared them better about them not being able to have this opportunity by telling them he had died before they went to see him and discover this themselves. This was significant information they expected staff to tell them about.
106. As staff did not tell Miss Q’s family, the way they found out about Mr Q’s death was more distressing. We consider the Trust’s poor communication has had a significant impact on Miss Q’s and her family’s last memories of Mr Q. On this basis, we went on to consider whether the Trust did enough to address this injustice.
107. We use our Principles for Remedy to consider whether an organisation has addressed injustice. We also have regard to the outcomes the person complaining seeks.
108. Where an organisation cannot put someone back in the position they would have been in had the poor service not occurred, our Principles for Remedy say the things Miss Q wants are appropriate remedies. We explained what she wants in paragraph seven. We looked at whether the Trust provided these things already.
109. During its complaint process, we saw the Trust explained why staff did not tell Miss Q’s family Mr Q had died between them arriving on the ward and going to see him.
110. In the Trust’s resolution meeting, it said there was a gap in communication between staff on the ward and Miss Q’s family. Staff at the meeting considered the limited time between her family arriving and them going to see Mr Q explained the omission.
111. We recognise Miss Q challenged this in the meeting and considered staff had enough time to tell her. That said, we saw the Trust explained why it considered the omission happened. This is what our Principles for Remedy say an organisation should do.
112. In the resolution meeting and in the Trust’s letter following the meeting, it apologised about the way Miss Q and her family found out Mr Q died.
113. To learn lessons from what happened and improve, our Principles for Remedy say organisations can do any combination of the following:
• revise procedures to prevent the same thing happening again • train or supervise their staff.
114. The Trust’s letter following its resolution meeting explained the senior nursing staff at the meeting reflected on what happened with the nursing team involved. This was to improve how staff communicate. This is a form of training with a supervisor.
115. Having considered all the above, we saw the Trust gave Miss Q explanations and an apology. It took action to try and prevent the mistake staff made happening again. This is in line with our Principles for Remedy.
116. That said, the Trust did not give Miss Q a financial remedy. Our Guidance on Financial Remedy says this is something the Trust should do in the circumstances. On this basis, as we explain further below, we saw there was more the Trust should do to remedy the injustice we saw.
117. Our Guidance on Financial Remedy says where poor communication had a significant impact on the surviving family’s last memories of the person affected, these cases fit into level four of our severity of injustice scale. This is the kind of injustice we saw on this matter.
118. Where we see injustice fitting into level four of our severity of injustice scale, our Guidance on Financial Remedy says we can recommend an organisation pays a financial remedy of between £1,250 and £3,700.
119. To decide on a level of financial remedy, along with our severity of injustice scale, we review similar cases where the person involved experienced similar injustice. Following this review, we concluded the Trust should pay Miss Q £1,562.50 in recognition of the injustice we described in paragraph 104 to 106.
120. We shared this thinking with both Miss Q and the Trust. Miss Q told us she accepted this remedy. The Trust also agreed to pay her this amount.
121. On the basis the Trust agreed to pay the financial remedy, we saw there was no further action we would expect it to take according to our Principles for Remedy. This meant we were able to resolve this part of Miss Q’s complaint.
122. We recognise the Trust’s financial remedy will not change the way Miss Q and her family discovered Mr Q died, and the distress this caused. We do not underestimate how difficult this was for them.
123. We hope the financial remedy the Trust has agreed to provide helps bring Miss Q closure on this matter.
124. We hope our explanations on the other parts of her complaint help assure Miss Q about the standard of care staff gave Mr Q. We also hope the actions we explained the Trust took to learn lessons from its poor communication assures her it has taken steps to improve. We appreciate it is important to her that the Trust learns from what happened.