14. Miss A told us the Trust had not got to the bottom of what was wrong with her Mum and had suggested different things. It is clear from what she told us how well she looked after her Mum, so we understand why this was such a worry.
15. We looked to see if the assessments the Trust undertook to try and find a cause for Mrs B’s symptoms were in line with guidance.
16. The NICE guidance, ‘Acutely ill adults in hospital: recognising and responding to deterioration’, says:
‘Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have:
• physiological observations recorded at the time of their admission or initial assessment • a clear written monitoring plan that specifies which physiological observations should be recorded and how often.
The plan should take account of the:
• patient's diagnosis • presence of comorbidities • agreed treatment plan.’
17. We can see this happened. The doctors took a clear history and noted details of the problem that had brought Mrs B to hospital, her recent history, as well as her history of underlying medical problems. These included Parkinson’s disease, dementia and asthma, along with the new diagnosis of probable aspiration pneumonia.
18. The doctor carried out a thorough physical examination, took blood tests and recorded the observations. The initial assessment noted the likely diagnosis was aspiration pneumonia (a type of pneumonia that’s caused when a patient accidentally breathes in food, or vomit, which causes a significant infection and/or inflammation).
19. The records show the initial assessment also suspected respiratory acidosis (when the lungs can't remove enough carbon dioxide from the body, leading to shortness of breath and other physical symptoms). The Trust reached this differential diagnosis (identifying most likely cause of symptoms) following the steps in the guidance outlined above.
20. Our adviser said it was a reasonable diagnosis to make. They explained people with Parkinson’s disease are at risk from chest infections. This was confirmed by blood tests. Later test results also confirmed the suspicion of respiratory acidosis and showed that Mrs B had Type 2 respiratory failure. This is when the patient has low levels of oxygen and high levels of carbon dioxide.
21. Our adviser noted Mrs B also had COVID-19 and may have had this for several days, which could have added to her general overall poor condition and deterioration.
22. The initial assessment noted Mrs B was too unwell for a CT scan and our adviser said this is supported by the records, which showed Mrs B had underlying conditions of Parkinson’s disease, dementia and asthma, as well as the acute conditions outlined above.
23. The doctors recorded a clear plan for Mrs B which included NIV, antibiotics and medication to help with Mrs B’s breathing, the infection and for her Parkinson’s disease. This plan was in line GMC Good Medical Practice, which says ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’
24. To summarise, the assessments were in line with guidance. Sadly, Mrs B’s condition did not improve, but deteriorated despite all treatments given. Our adviser said the underlying causes of her ill health, such as aspiration pneumonia and COVID-19 may have been advanced, and this is what likely led to the respiratory failure and her sad death.
25. Miss A told us she was worried that the Trust may have given her Mum too much medication. We asked our adviser to look at the medications listed in the records so we could see if there were any indications she was given too much, or the wrong medication.
26. Our adviser told us the medications the Trust gave to Mrs B are all commonly used for the conditions she was diagnosed with. They were prescribed in line with the GMC guidance which says:
‘a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b. provide effective treatments based on the best available evidence’
27. We can see the Trust gave Mrs B:
• antibiotics to help with the suspected chest infection • steroids to help in reducing airways inflammation and improving breathing • paracetamol for pain relief • nebulised medications to help with her breathing • Parkinson’s medication • magnesium which is known to have a beneficial effect for patients with acute asthma attacks • intravenous aminophylline which helps in improving breathing.
28. Our adviser said there is no record of any medication that would have caused Mrs B harm in the list of medications, or the infusions the Trust gave her. All of these medications were given following a thorough assessment as outlined in paragraphs 16 to 18.
29. We know Miss A is concerned the Trust did not move her Mum to the ICU. She told us she thinks the Trust might have resolved her problems if they had cared for her there. We looked at the decision making about this.
30. The records show the Trust decided Mrs B’s underlying conditions of Parkinson’s disease, dementia and asthma, along with the likely diagnosis of aspiration pneumonia, would mean that she would be too frail to withstand the intrusive levels of input required by an ICU admission (such as invasive ventilation).
31. This decision was made by the emergency department clinician, with a second opinion by the ICU consultant. This was in line with the GMC guidance that says:
‘In providing clinical care you must:
a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b. provide effective treatments based on the best available evidence c. take all possible steps to alleviate pain and distress whether or not a cure may be possible d. consult colleagues where appropriate’
and
‘refer a patient to another practitioner when this serves the patient’s needs’.
32. The decision by the doctors caring for Mrs B, along with the opinion of the ICU consultant, showed the Trust gave careful consideration about where she would be best looked after and treated. This was also in line with the NICE guidance which says:
‘For patients in the high- and medium-score groups [deteriorating patients], healthcare professionals should:
• initiate appropriate interventions • assess response • formulate a management plan, including location and level of care.’
33. We cannot reach the conclusion Miss A suggested, that if the Trust had transferred Mrs B to the ICU, they may have resolved her problems. The records show that despite the early non-invasive ventilation the Trust gave her, she began to deteriorate very quickly.
34. Our adviser explained she was given all available treatments that she was able to withstand. As outlined in paragraph 30, her pre-existing conditions coupled with her acute illness increased her frailty. People who are frail have poorer outcomes when looked after in ICU, and this is why there needs to be careful consideration, as happened here, of whether it meets their best needs.
35. Miss A told us she was also concerned the Trust did not use suction to remove mucus. She told us she was worried the mucus entered her Mum’s lungs and worsened her condition.
36. When Mrs B was assessed by the medical team they noted she was ‘wheezy’. Our adviser told us there is no evidence Mrs B had mucus on her lungs that needed to be suctioned. They explained patients with mucus on the lungs are not wheezy, but are noted to have ‘crackles’.
37. The Trust gave Mrs B nebulisers (used to thin down secretions). This was in line with the GMC guidance that says:
‘a prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs B provide effective treatments based on the best available evidence.’
38. There is additional evidence in the records to show there was no mucus. The chest X-ray said ‘Clear, no consolidation’. This means no sign of collapse of any portion of the lungs due to mucus impaction.
39. Our adviser also told us it is important to not carry out suctioning unless necessary in a patient who has had a possible episode of recent aspiration. This is because deep suctioning can often provoke a gag reflex. People wearing a NIV mask, as Mrs B was, are at a higher risk of aspirating vomitus and any risk of vomiting must be avoided.
40. To summarise there was nothing to show Mrs B had mucus or that mucus was in anyway linked to the respiratory failure that led to her sad death.
41. We understand how important this complaint is to Miss A and we thank her for sharing her concerns with us. We hope she will be reassured that we have not found anything to make us think we need to ask the Trust to take further action in relation to the issues we considered.