Antibiotics
24. Mrs K received antibiotics between 12 and 15 November 2022 but Mrs J is concerned staff failed to notice her deterioration in the days leading up to her 24 November discharge.
25. She says doctors should have prescribed further antibiotics and their failure to do so seriously limited her mother’s chances of making a recovery when she was again admitted to hospital in early December.
26. We previously considered the Trust’s use of antibiotics between 12 and 15 November 2022 and we are satisfied it acted in line with applicable guidance and standards.
27. Following discussion with Mrs J, we agreed to consider whether staff correctly treated Mrs K during the remaining period between 15 and 24 November.
28. The Trust says it correctly administered antibiotics when Mrs K showed signs of infection.
29. GMC guidance sets out how a doctor can provide good care. Under section 15, it says doctors must provide suitable advice, investigation and treatment where necessary.
30. We can see Mrs K received nitrofurantoin antibiotics for a UTI on 12 to 15 November, and again on 18 to 25 November. The period without antibiotics was therefore between 16 and 17 November.
31. Our physician adviser says her medical records between 16 and 17 November do not suggest Mrs K was unwell with infection or sepsis (which would warrant urgent antibiotics).
32. A consultant ward round on 16 November found Mrs K was not unwell and was thought to be medically stable for discharge.
33. A doctor’s ward round on 17 November also found Mrs K was not unwell, but there appears to be acknowledgement of the family’s concern around her decline in mobility and the doctor recorded that she was hallucinating at times.
34. Upon examination, the doctor recorded Mrs K was mildly confused, had strong smelling urine, was mildly tender over the lower abdomen and had ‘rigidity’ which is consistent with her Parkinson’s disease. The doctor’s impression was that Mrs K’s Parkinson’s disease was worsening with an underlying UTI and delirium.
35. A consultant ward round on 18 November concluded Mrs K had a partially treated UTI and delirium.
36. Our physician adviser explains the nursing and therapist entries throughout this period do not suggest Mrs K was acutely unwell with sepsis or infection. Observations made by other clinical staff appear to support this, and there is no evidence of fever.
37. Blood test results showed normal white cell counts and minimally elevated C-reactive protein (CRP) levels which suggests no infection was present.
38. CRP is a substance produced by the liver in response to inflammation in the body. Elevated CRP and white cell counts are therefore a good indicator of infection.
39. Our physician adviser says Mrs K’s off baseline mobility and her being more confused than usual fits with the recovery phase of infection. Strong smelling urine is not a reliable feature of a UTI and fits with urinary incontinence which may happen with delirium.
40. Our physician adviser adds that the tenderness over the lower abdomen is a feature of a UTI but may continue after infection has resolved. They also note that delirium is known to outlast the infection which caused it.
41. For the reasons set out above, we have not seen any clear evidence to show Mrs K was suffering from infection during the 16 to 17 November period which would justify antibiotics.
42. Our physician adviser says the recommencement of antibiotics from 18 November is therefore most likely to have been a precautionary measure, erring on the side of caution in case there was any residual infection.
43. We are therefore satisfied doctors managed Mrs K antibiotics in line with GMC guidance.
Parkinson’s disease medication
44. Mrs J tells us she gave a chart to medical staff on 6 November which set out the daily timings of Mrs K’s various medications. This chart included her Parkinson’s disease medication regime.
45. She says staff assured her they would administer her mother’s Parkins’s disease medications in line with this regime. Despite this, Mrs J tells us staff regularly seemed unsure about the drug timings, and this led to missed or delayed doses of her Parkinson’s disease medication.
46. Mrs J says the missed or delayed doses worsened her mother’s mobility and her ability to recover.
47. The Trust acknowledged there were three separate occasions where it prescribed Mrs K’s Parkinson’s disease medication incorrectly, but it said it adjusted it accordingly. It acknowledged the distress this caused to Mrs J and the family and offered an apology.
48. NICE quality standards say levodopa (Parkinson’s disease medication), which we refer to as co-careldopa in this statement, should be administered within 30 minutes of a patient’s individually prescribed administration time. It says serious complications can develop if co-careldopa is not taken on time.
49. We have seen mistakes in the Trust’s handling of Mrs K’s co-careldopa Parkinson’s disease medication. Our statement will focus on this drug, which is used to treat the main symptoms of Parkinson’s disease. We are aware Mrs K was taking other medications for her Parkinson’s disease, but it is less imperative for those medications to be given on time.
50. We found some mistakes in the administration of co-careldopa, for example: • administration was often delayed by more than 30 minutes • on 13 November staff gave co-careldopa (25mg/100mg) five times during the day instead of four • on 8 to 10 and 15 to 18 November staff administered co-careldopa spaced along the lines of how most four-times per day drugs are given. This is not the usual regime for Mr K’s Parkinson’s disease medication. This means when staff gave the last dose of her 12.5mg/50mg co-careldopa and her 25mg/100mg co-careldopa in the late evening, they did so around the same time as her late evening dose of modified release (MR) 25mg/100mg co-careldopa. It appears the Trust administered too much medication just before bed with too little during the earlier part of the day.
51. From the 19 November onward, it appears staff largely adhered to Mrs K’s medication regime and administered her co-careldopa correctly.
52. We see indications of failings as staff do not appear to have handled Mrs K’s co-careldopa in line with NICE quality standards.
53. We asked our Physician adviser whether there is any evidence to suggest these mistakes had a clinical impact upon Mrs K.
54. Our Physician adviser says there is nothing to suggest Mrs K suffered serious complications associated with delayed co-careldopa administration.
55. They note there is mention of her tremor being poorly controlled, but this appears to be the only complication they could find in the medical records which could be linked to poor co-careldopa management, and this is only mentioned earlier in the admission. We recognise Mrs J’s account also says her mother was ‘shaking’ when she arrived at her mother’s bedside on 17 November.
56. Mrs K’s mobility was off baseline according to her physiotherapy entries, but our Physician adviser notes this was most likely due to multiple factors.
57. Overall, our Physician adviser says Mrs K’s UTI with delirium and deconditioning (the decline in physical and mental function due to reduced activity and increased bed rest) likely played a more significant role in her slow recovery.
58. Based on the evidence we have seen, we are not persuaded the indicated failings around the handling of Mrs K’s Parkinson’s disease medication had a clear clinical impact upon her, aside from a transient tremor.
59. We acknowledge these issues were known to Mrs J at the time, and it likely had an emotional impact upon her. We understand Mrs J was upset and distressed medical staff seemingly did not act in line with, or were unsure of the medication regime she supplied on 6 November.
60. Our complaint standards say providing fair and proportionate remedies is an integral part of good complaint handling. Where a public body has failed to get it right and this has led to injustice or hardship, it should take steps to put things right.
61. At this stage, we have already found indicated failings in the Trust’s handling of Mrs K’s co-careldopa medication. We can see the Trust does not dispute this as it appears to agree it made mistakes.
62. After careful consideration, we felt it was more suitable and beneficial for all involved to attempt to resolve this element of the complaint at this earlier stage.
63. We contacted the Trust and made it aware of what we have seen. We asked whether it would be willing to set out how it would improve its service, so the same mistakes are not repeated.
64. The Trust says it has now improved its medicines reconciliation rates (ensuring a patient’s list of medications are up to date) which staff complete at the earliest possible stage following a patient’s arrival. It says this is helping to drive up the accuracy of the patient’s prescriptions on admission and provide more accuracy around when those drugs are administered.
65. It has reorganised its clinical pharmacy team so it can deal with urgent overnight medication requests more quickly.
66. The Trust also says it now has a dedicated slot for a clinical pharmacy assistant to bring critical medicines from the dispensary to the Emergency Department (ED), which will avoid any delays in administration of medication in this area.
67. It says its Patient Experience Team (PET) invites patients and relatives to share their personal experience by participating in a ‘Patient/Relative Voice Session.’ These sessions take audio recordings of their experiences.
68. PET uses those recordings in staff training sessions which are attended by both clinical and non-clinical staff. The Trust says the recordings are a valuable and powerful way of capturing a patient’s or family’s personal experience and can be used to great effect in driving further improvement of its service.
69. The Trust says it would like to invite Mrs J to attend its Patient/Relative Voice Session but recognises she has been through a great deal already, so this may not be something she would like to engage with.
70. Should Mrs J want to engage with this service, she should let the Trust know.
71. The Trust has also agreed to write to Mrs J to acknowledge its mistakes and to further apologise for the distress and upset caused to her.
72. We think the Trust’s actions are in line with Our complaint standards and are proportionate to put right the indicated failings we identified in this statement. They are also the outcomes Mrs J was seeking.
73. We have therefore decided to take no further action in Mrs J’s complaint.
74. We recognise Mrs J is very upset about the care her mother received. We hope our statement can in some way provide reassurance in this matter.
75. We also hope the Trust’s willingness to further engage with Mrs J to continue to improve its service will add to this reassurance.