East of England Ambulance Service NHS Trust
20. Mr E says the ambulance crew incorrectly assessed his mother’s condition as being ‘fine’ and ignored the families’ requests for her to be taken back to hospital on 22 August 2021.
21. The ambulance Trust says the crew knew Mrs E was not ‘fine’ but were doing what they felt was best for her by helping her to remain comfortable and cared for at home. The crew’s clinical assessment did not reveal any time critical necessities which needed urgent hospital treatment at the time of the assessment.
22. JRCALC ambulance service guidelines advise a step-by-step approach to patient assessment and history taking. It says the ambulance clinician should firstly obtain information about the initial presenting complaint and why the initial call was made, followed by the history of the presenting complaint. This includes gathering relevant information about the patient, including the recent events, past medical history, medications, social situation and allergies.
23. The ambulance clinician should then complete a primary and secondary survey. The primary survey is done quickly to rule in or out any immediately life-threatening issues. The secondary survey involves a more detailed physical examination of the patient. As part of this assessment, clinical observations (inc. pulse rate, blood pressure, temperature, respiratory rate) should be recorded. These observations are allocated a ‘score’, depending on how much they may deviate from normal parameters. These totals are combined to form a national early warning (NEWS) score. The higher the score, the more potentially unwell the patient is.
24. Our paramedic adviser tells us making a clinical decision on whether to take a patient to hospital is not always straightforward. JRCALC does not offer specific guidance on every patient group and individual clinical judgment is required by the ambulance clinician.
25. The notes show ambulance clinicians documented Mrs E was clinically stable, with no immediately life-threatening symptoms. Her observations within normal parameters and she had a NEWS2 score of zero (suggesting a low-risk patient). The crew documented Mrs E was fully alert with no obvious confusion or delirium and the primary concern was her ability to manage at home and the family were unable to access appropriate care services.
26. Following assessment, the ambulance clinicians documented that if suitable analgesia could be arranged, Mrs E would be able to mobilise as usual and therefore be able to self-care. They contacted the out-of-hours GP to make a referral via local pathways for a package of care to be discussed or arranged. Mrs E had a supply of strong analgesia (codeine) she could take until after the weekend when her own GP could be contacted.
27. We fully appreciate Mr E, and his family were struggling to care for his mother at home and they feel their wish for her to return to hospital was ignored. We do not doubt how difficult and upsetting this was for them. We can see the ambulance clinicians fully assessed Mrs E in line with JRCALC guidelines and exercised clinical judgement that she did not need to go back to hospital as her observations were stable. The main issue was dealing with Mrs E’s care needs at home and the ambulance clinicians made the appropriate referral for this to be arranged. We consider the ambulance clinicians acted appropriately and we cannot see any indications something went wrong.
Northwest Anglia NHS Foundation Trust
Discharge on 20 August:
28. Mr E says the hospital Trust discharged his mother on 20 August when she was not fit to do so. He also says the hospital Trust did not put a care plan or a dietary and medication plan into place when discharging her. The hospital Trust says clinicians assessed Mrs E and she was fit for discharge.
29. GMC Good Medical Practice Guidelines says:
‘15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient’
30. NMC guidance says nurses should:
‘4.18 demonstrate the ability to co-ordinate and undertake the processes and procedures involved in routine planning and management of safe discharge home or transfer of people between care settings’.
31. The Department of Health (DOH) Hospital Discharge Service policy says:
‘Hospital discharge is the final stage in an individual’s journey through hospital following the completion of their acute medical care, when they leave an acute setting and move to an environment best suited to meet any ongoing health and care needs, they may have. This can range from going home with little or no additional care (simple discharge), to a short-term package of home-based or bed-based care and recovery support in the community, pending assessment of any longer-term care needs (complex discharge). Whether at home or in a community setting, individuals should be discharged to the best place for them to continue recovery (if needed) in a safe, appropriate and timely way’.
32. The DOH policy also lists the criteria for a patient to stay in hospital. The criteria includes if a patient requires an intensive therapy unit, if their NEWS score is greater than three, or if the patient has recently had an invasive procedure.
33. The hospital Trust admitted Mrs E to hospital on 5 August. She had pre-existing liver disease and an acute kidney injury. During this admission, clinicians diagnosed and treated her for community acquired pneumonia. The notes show these conditions improved during her admission.
34. During the ward round on 18 August, the clinician noted Mrs E ‘appears much improved’ and she was able to sit out in her chair. The following day, a clinician noted Mrs E was no longer short of breath and her acute kidney injury had resolved. On 20 August (the day of discharge), the treating clinician recorded Mrs E was ‘doing well, eating and drinking’, mobilising to the bathroom and there was no clinical jaundice.
35. National early warning score (NEWS) is a tool to assess the degree of illness of a patient and whether escalation is needed. It assigns a score to six parameters: respiratory rate, oxygen saturation, temperature, blood pressure, heart rate and level of consciousness. The aggregate scores range from zero to twenty. A score of one to four means there is low risk of sudden deterioration. Mrs E’s NEWS score was zero on the day her discharge and it was zero or one for more than three days before her discharge, which suggests her condition was stable.
36. There is no indication from the notes Mrs E met the criteria to stay in hospital. This means that whilst she had ongoing medical health needs, she no longer required acute medical care. Our physician adviser says all the pre- discharge assessments were appropriate and carried out in line with GMC guidance.
37. Nursing staff assessed Mrs E’s risk of malnutrition on admission, and documented she had a low risk and was independent with meals and snacks. On discharge staff noted Mrs E was taking oral medications but there were no complex medication regimes. Our nursing adviser explains this means there would be no need to arrange support with medications on discharge. The notes show Mrs E was able to mobilise with a zimmer frame. The therapy team assessed her as safe on transfers from bed to chair and toilet. Mrs E advised she had a shower and toilet downstairs and that her bed was being moved downstairs. The team referred her to the Community Therapy Team for ongoing assessment within her own home.
38. There is no indication from the notes Mrs E lacked capacity to be involved in discharge planning. She lived with her husband and had no package of care prior to admission. On the day of discharge, Mrs E said she wanted to go home that day and did not want to wait until equipment was delivered. Our nursing adviser says Mrs E had the capacity to make this decision and as she had been safe in mobilising during her assessments, and had no further nursing needs, the Trust staff arranged this. Given Mrs E was independently eating and drinking, was able to mobilise with a frame and transfer out of bed and chair, our nursing adviser says there was no requirement for a medication or dietary plan on discharge. This was in line with NMC and DOH guidance.
39. We are very sorry to hear how Mrs E’s condition deteriorated at home and her family struggled to care for her. From the evidence we have considered, we cannot see indications Mrs E was clinically unfit for discharge on 20 August, and we cannot see the hospital Trust handled her discharge inappropriately. We will therefore not take any further action on this part of Mr E’s complaint.
Intensive care/ medication drip:
40. Mrs E was taken back to hospital by ambulance on 24 August. Mr E says clinicians kept his mother in the Emergency Department instead of taking her straight to intensive care. Mrs E complains clinicians took his mother off the fluid and medication drip towards the end of her life. The hospital Trust say Mrs E was under the care of the urgent/ acute medical team and they sought advice from the intensive care team on her ongoing care and management.
41. The notes show clinicians assessed Mrs E in the ED at around 11pm. They noted Mrs E had significant acute kidney injury and liver decompensation (deterioration of liver function). Clinicians started treatment with fluids and antibiotics.
42. At around 1am, the medical registrar reassessed Mrs E following initial treatment, and sought opinion from the intensive care unit. The critical care team assessed Mrs E and advised they could add little to her management. She sadly continued to deteriorate, despite treatment. The notes show clinicians explained to Mrs E’s family that sadly her prognosis was poor. At 8:25am, at the request of Mrs E’s family, she was re-escalated to the critical care team for consideration, and they agreed for her to be transferred.
43. World journal of hepatology journal article says cirrhotic patients account for 2.3% and 4.5% of all intensive care units (ICUs) admissions and their mortality is traditionally high’…the occurrence of three or more organ failures in cirrhotic patients has an almost certain fatal outcome. For ethical reasons and due to limited resources, physicians need to be able to quickly identify cases that benefit from aggressive treatment and ICU admission, discriminating good candidates for ICUs from those for whom the prognosis is poor despite strong therapeutic interventions’.
44. The faculty of intensive care medicine guidance says, ‘for some patients, it is not clear that treatment in a critical care unit is going to be the best care for them… it is possible [critical care treatments] may harm the patient more than they might help them…Critical care teams will look at all a patient’s treatments and medications to see if they are helping them. Any treatment that doesn’t bring comfort to the patient or help towards a good death may be stopped’.
45. As set out in the hepatology journal article, the risk of death in patients with decompensated liver failure is sadly very high. Our intensive care adviser explains, the prognosis is not usually altered by admitting patients to the Intensive Care unit. For this reason, many intensive care units do not admit patients such as Mrs E as palliative and end of life care can offer a more peaceful end to life.
46. The notes show clinicians had several discussions with Mrs E’s family about the ineffectiveness of treatment with the diagnosis of decompensated liver disease and multiorgan failure. Mrs E had her care escalated to include vasopressors to maintain blood pressure and renal replacement therapy to support her kidneys. Despite this care, her condition continued to deteriorate. A do not attempt cardiopulmonary resuscitation (DNACPR) order was therefore completed on 25 August which said the focus would be on symptom control, rather than life-sustaining treatment. Our intensive care adviser says this was appropriate as enhanced medical care was failing and causing more harm than benefit. It was therefore appropriate and in line with the intensive care society guidelines to withdraw active medical interventions and allow Mrs E a peaceful and dignified death.
47. We fully appreciate Mr E’s strength of feeling about this and recognise the distress he and the family experienced as his mother sadly neared the end of her life. We cannot see there was delay in Mrs E being admitted to the intensive care unit. Clinicians arranged for the ITU to assess her shortly after she arrived, but they did not think she was suitable. We are not critical of this decision. We also consider cannot see the Trust got something wrong when it decided to withdraw active treatment.
Transfer:
48. Mr E says the hospital Trust should have transferred his mother to another hospital (hospital B) that has an expert in dealing with her condition.
49. Paragraph 14(c) of GMC Good Medical Practice guidance says ‘refer a patient to another practitioner when this serves the patient’s needs.
50. Our ICU adviser explains the majority of patients with liver problems are managed in district general hospitals. Usually only those patients who may require liver transplantation are transferred to specialist units. It is usual practice for patients to be discussed with the local specialist unit if required. We can see from the notes this happened in Mrs E’s case. Clinicians contacted specialists at hospital B on 24 August, and they advised care should continue in the local hospital.
51. We understand Mr E feels his mother may have received better care had her care been transferred. We can see clinicians at the hospital Trust sought appropriate input specialists in line with section 15 of the GMC guidance and there was no indication they should have transferred her to another hospital for ongoing care.
52. Overall, we have not seen the care and treatment the hospital and the ambulance Trust’s provided to Mrs E fell below the expected standard. We thank Mr E for taking the time to bring his complaint to us and hope our decision provides Mr E and his family with some reassurance.