22. When deciding if we should conduct a detailed investigation of a complaint, we look at whether there are signs an organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications something went wrong with the Mr B’s clinical care
23. We have seen issues with Dartford Trust’s communication, that there was a delay in it returning Mr B’s body and it sent his personal effects to the wrong address. Where it appears things did go wrong, we then look at whether these had a negative effect which the organisation has not put right. Having done so we found Dartford Trust has already done enough to put right the impact of what happened..
Frimley Trust
Visiting restrictions 24. Frimley Trust explained Mr B attended hospital during the second wave of the COVID19 pandemic. It said visiting restrictions at the time were Trust-wide, and not specific to the intensive care unit (ICU) where it was looking after Mr B. It explained inpatient visiting was not allowed in order to protect patients and staff from disease transmission.
25. To understand what happened we referred to Frimley Trust’s visiting policy and visiting flowchart.
26. It allowed just one visitor for up to one hour once every three days. However, if any wards were closed to admissions following patients testing positive for COVID-19 then all visiting on that ward was suspended. From the flowchart it appears the exception to this rule was when a patient was in the last week of their life.
27. Our adviser explained Mr B was not considered to be in the final week of his life.
28. As the ICU was handling COVID-19 cases at the time we consider it was in line with policy to suspend visiting to the ward. Sadly, this meant Mrs E could not visit her father.
29. We recognise this has caused her immense upset and made an exceptionally upsetting event even worse.
Oxygen mask 30. Mrs E complains doctors should not have given her father an invasive oxygen mask on 19 January. She says the mask caused him distress and meant staff had to place him in an induced coma. She says this induced coma led to him being given the invasive ventilator.
31. Frimley Trust referred to British Thoracic Society: Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings.
32. It explained this guidance recommends oxygen treatment for COVID-19 patients when their blood oxygen drops to below 94%. It said this ensures patients have enough oxygen in their blood and prevents deterioration or death.
33. When doctors examined Mr B on 19 January his blood oxygen saturation was 87%. They noted he was confused and had ischaemic heart disease. This is when someone’s arteries become narrower. Doctors gave Mr B oxygen and his saturation rose to 95%.
34. Our adviser agreed Frimley Trust referred to the relevant standard. It sets out ‘Oxygen should be prescribed to achieve a target saturation of 94–98% for most acutely ill patients’, and ‘staff should use appropriate devices and flow rates in order to achieve the target saturation range’.
35. Our adviser said it was appropriate for staff to correct Mr B’s oxygen levels using a mask. They explained not doing so would have likely worsened his confusion, as this is a symptom of low oxygen levels. Furthermore, low oxygen levels would have put additional strain on his heart.
36. We consider the decision to correct Mr B’s low oxygen saturations was appropriate, and there is no indication it was wrong for doctors to use a mask to do this.
Transfer to Medway Trust 37. Frimley Trust explained it faced pressures to free beds at the time due to COVID-19. It told Mrs E and her family that Mr B was the least vulnerable patient on the ward at the time, and this was the reason it decided to move him.
38. Frimley Trust’s intensive care lead told us when Mr B was in the department it experienced very high pressures with the number of COVID-19 cases. This meant it did not have available resources to treat them all. In these circumstances, patients who are safe to be moved are transferred to another ICU with available capacity.
39. The decision on which hospital the patient is moved to is decided at a regional level. However, which patient to move is decided by senior team members of the ICU. This is usually the consultant and the nurse-in-charge. It is based on the patient’s current and predicted condition, and will be discussed with the receiving ICU ahead of time.
40. Guidance in place at the time was the Department for Health and Social Care’s COVID-19: Guidance for infection prevention and control in healthcare settings. This provided advice for healthcare workers when managing the prevention and control of COVID-19.
41. Section 6.3.3 of the guidance sets out that transferring a patient from one healthcare facility to another should be avoided, and only undertaken if medically necessary. If transfer is essential then the ambulance service and receiving hospital should be informed.
42. FICM’s Guidelines for the Provision of Intensive Care Services apply here. Although first published in 2019, we have referred to version 2.1 released in July 2022. This is because the original did not include lessons learned from the COVID-19 pandemic when intense pressures meant standard procedures could not be applied.
43. FICM’s updated guidelines say capacity transfers should be regarded as a system failure in all but the most extreme pandemic scenarios. Even still, capacity transfers should only be used as a last resort in a surge situation.
44. We are unable to reach a view on whether Mr B was actually the least vulnerable patient on the ward as we cannot compare his condition to other patients at the time. However, we have considered whether Mr B was in good enough health to be moved.
45. Our adviser explained Mr B’s condition was stable at the time. This meant his condition was good enough to make transferring him a reasonable decision.
46. Furthermore, January 2021 was during the ‘second wave’ of COVID-19. It caused intense pressures on critical care beds and ICUs sometimes reached capacity. Given the pressures on ICUs at the time we do not consider it was a failing Frimley Trust transferred critical care patients to different hospitals.
47. We acknowledge how much this issue means to Mrs E. We understand how concerning it was that her father was moved to a different hospital and she sadly never saw him again. It was a tragic set of circumstances that understandably caused a lot of distress.
Medway
Transfer to Dartford Trust 48. Medway Trust apologised to Mrs E for what it was doing at the time, and explained it was unusual to transfer patients like this. Its complaint response explained its ICU was experiencing increased demand at the time due to the second wave of the COVID-19 pandemic.
49. The response explained it moved Mr B as a ‘capacity transfer’ to make room for the most critically ill COVID-19 patients. It said Mr B was chosen because he was the most stable patient on the ward.
50. The national guidance we have referred to is the same as that set out above. Additionally, Medway Trust had its own policy in place. Specifically, its standard operating procedure. This set out consultants were responsible for the decision to transfer patients and identifying which ones were suitable.
51. At the time of the transfer Mr B was sedated. His ventilator was providing 50% of the oxygen he needed, his blood pressure was good and he had a body temperature of 38.3°C.
52. At 10.22am on 24 January a consultant reviewed Mr B and decided he was stable enough for transfer. The consultant spoke to their colleague in the ICU at Dartford Trust and made plans to move Mr B.
53. Our adviser explained Mr B’s condition at the time was relatively good. His oxygen requirement was not high and the rest of his body was working on its own. This meant he was ‘physiologically stable’.
54. We therefore consider Mr B’s condition at Medway Trust was good enough for him to be transferred considering the pressures the ICU faced at the time. The decision was made amongst two consultants – one at Medway Trust and the other at Dartford Trust. This demonstrates best practice and was in line with national and local guidance.
Dartford Trust
Deterioration 55. Mrs E complains within a day of arriving at Dartford Trust her father had a heart attack and his condition deteriorated rapidly. She says he went from being the most stable person on the unit to going completely ‘down-hill’. Mrs E says her father’s condition never returned to normal.
56. Dartford Trust explained when Mr B arrived in the ICU he had a blood test. The results showed a ‘massively raised High Sensitivity Troponin’. This usually indicates a myocardial infarction (heart attack), and typically rises three to four hours after a heart attack happens.
57. It added Mr B’s heart attack was extremely likely to have started before or during his transfer there.
58. Dartford Trust went onto explain Mr B’s COVID-19 infection, in addition to his underlying heart disease, meant he was at a higher risk of heart attack. It said all these factors combined led to the deterioration Mr B experienced.
59. Our adviser explained Mr B’s heart attack was just as likely to have occurred as a complication of Mr B’s COVID-19, his heart disease and his critical illness. This meant Mr B’s heart attack could not be predicted and was not preventable.
60. We recognise how upsetting Mrs E’s experience has been. We cannot imagine how distressing it must have been to learn about her father’s heart attack and sudden deterioration.
61. We know Mr B was well enough to be transferred from Medway Trust to Dartford Trust. The fact his heart attack could not have been predicted means we do not consider it was a failing it was not prevented, or that his deterioration happened.
Transition to end-of-life care 62. Mrs E complains staff at Dartford Trust stopped actively treating her father's illness. She feels Dartford Trust 'gave up' on trying to make him better.
63. Dartford Trust's complaint response explained Mr B was already very poorly when he arrived at hospital. It explained this was indicated by the DNACPR (do not attempt resuscitation) already in place, alongside his COVID-19 and a myocardial infarction.
64. FICM guidelines Care at the End of Life set out how doctors should look after patients who are at the end of their life, like Mr B. It says effective end-of-life care involves: • individualised symptom assessment and management • a duty to understand patients’ values and beliefs and meet such needs • collaboration with the family of the dying patient enhances care and experiences • clear, non-ambiguous communication.
65. The overall aim is to ensure the patient is the focus of care and allowed to have a dignified, natural death.
66. Consultants called Mr B’s family at 10.07pm on 25 January, and at 4.50pm the following day.
67. They had very clear conversations about how unwell Mr B was, the poor likelihood of overall survival and the development of any further deterioration being considered as a point to consider end of life care. Although this future plan was in place, all other intensive care treatment at that point continued.
68. The decision to formally move to end-of-life care was documented later on 7 February with the creation of a personalised care plan. This was supported by a multidisciplinary review with other specialisms involved in looking after him, and communicated to Mrs E at the time.
69. Our adviser explained these actions were consistent with established best practice set out in the guidance.
70. Therefore, active treatment continued with a clear plan of what to do when Mr B’s condition got worse. When it did become worse he was transferred to end-of-life care in line with the plan. We are satisfied staff at the hospital treated him in line with guidance with respect to him approaching the end of his life.
71. We hope this reassures Mrs E that staff respected Mr B’s dignity, and they cared for him in the most appropriate way at the right time.
Ventilator placement 72. Mrs E complains when she saw her father in a video call he had sores around his lips. Mrs E says she asked the nurse at the time if it was due to the ventilator, and the nurse explained that was the likely cause. Mrs E feels if the ventilator had been placed properly then her father would not have developed these sores.
73. Dartford Trust explained when doctors received Mr B they recorded he had a scab on his lips. The doctor did not know what caused it, but it appeared similar to injuries in patients who had been lying on their front whilst ventilated. It explained this is consistent with notes from Medway Trust, which recorded Mr B had two cycles of prone positioning there.
74. The Intensive Care Society has published guidance on Prone Positioning in Adult Critical Care. This sets out nurses should document skin integrity and provide daily mouthcare.
75. Our adviser explained damage to the skin around the mouth is a recognised side effect of prone ventilation. Skin damage is caused by the pressure of the tube inserted into the mouth. The damage is not always avoidable, but can be reduced or prevented with regular nursing care and observations.
76. As Mr B appeared to have the sore on his arrival at Dartford Trust we have considered the notes from his time in Medway Trust as well. These nursing notes show he had regular mouth care every four-hours. Despite this, small tears on his lips appeared where they had cracked. When nurses noticed these, they applied cream and continued the regular mouth care.
77. Nurses at Dartford Trust also had a mouth care plan in place for Mr B. They checked the condition of his mouth daily, kept his mouth clean and clear, and applied soothing creams when needed.
78. Given the mouth care nurses provided to Mr B whilst he was ventilated, we do not consider it was a failing he developed sores. Nonetheless, we recognise how distressing it was for Mrs E to see her father’s injury. We understand how this made a distressing time so much worse.
Staff awareness of Mr B’s condition 79. Mrs E complains staff gave her incorrect information about Mr B. She says she spoke to a member of staff on the phone who said Mr B had a bleed on his leg and his blood was not clotting. In a later call with a different nurse, they explained Mr B’s notes did not have any information on this. Mrs E wonders if staff confused Mr B with someone else.
80. Dartford Trust explained there was nothing in Mr B’s notes about his legs bleeding. It added staff were wearing full personal protective equipment (PPE) at the time, which including face masks. It explained masks sometimes made communication more challenging and it was possible this may have caused the miscommunication.
81. Instead of focusing on whether something went wrong, we have considered how Dartford Trust responded to Mrs E’s complaint.
82. Our Principles for Remedy says organisations should explain what happened and why. They should accept responsibility and apologise for the impact of its actions. In this instance, Mrs E says what happened added to upsetting events she was experiencing and made her lose faith in the NHS.
83. The complaint response explained what probably happened and why. It also acknowledged the distress this caused and apologised for it.
84. Further, it appears what happened was a one-off instance of miscommunication at an exceptionally difficult time for everyone during the second wave of the COVID-19 pandemic. Also, a second member of staff provided clear information about Mr B soon after the call. This goes some way to mitigating what happened
85. We acknowledge Mrs E would like a financial remedy and service improvements to resolve her complaint. Given the Trust’s explanation and what it has done to put things right we do not believe a financial remedy is appropriate in this instance. Likewise, the isolated nature of this issue means it would not be appropriate to recommend service improvements.
86. With this in mind, we are satisfied the Trust has done enough to resolve the impact Mrs E has told us about.
Repatriation 87. Mrs E complains Dartford Trust delayed returning her father’s body after his death was delayed. She says she had to chase the medical examiner to arrange the transfer several times. She feels there was a disagreement between the Trusts, and neither of them wanted the responsibility or cost of moving her father’s body.
88. Dartford Trust’s medical examiner responded to Mrs E’s complaint. They explained Dartford Trust is used to returning the deceased home when they live within the hospital’s catchment area or the county. However, there was no guidance setting out what should have been done in Mr B’s case.
89. The medical examiner explained they discussed this issue with the relevant director at the Trust. The Trust’s executive team and clinical commissioning group (the body responsible for funding the Trust) spoke with their counterparts at the other Trusts involved in Mr B’s care. This was the reason for the delay in making appropriate arrangements.
90. The medical examiner added they completed Mr B’s death certificate the day after he died. They attempted to contact Mrs E several times between 8 and 14 February to provide an update. They explained they received no answer so left voicemails. The medical examiner contacted Mrs E again on 15, 16 and 18 February to make the final arrangements for transfer.
91. Mrs E disputes this and says she had no missed calls or voicemails from the medical examiner.
92. Our Principles of Good Administration say organisations should communicate effectively and tell people if things are going to take longer than expected.
93. Our Principles also say organisations should provide services that are easily accessible. Policies and procedures should be clear and there must be accurate, complete and understandable information about the service.
94. There are two competing accounts of whether the medical examiner tried to contact Mrs E. We accept Mrs E’s account that she did not hear from the medical examiner during this time.
95. However, it also possible the medical examiner made genuine efforts to get in touch. It appears the medical examiner made the calls and left the messages as claimed, but they were either to the wrong number or missed. With this in mind, the communication appears to be a shortcoming rather than a failing.
96. Nonetheless, we have seen there was a gap in the Trust’s policies. This meant it did not have clear procedures about what should happen in the circumstances Mrs E has told us about. This resulted in the delay returning Mr B’s body and appears to be a failing.
97. Mrs E says this added to her distress at an already upsetting time.
98. Dartford Trust also identified this gap in its policy. It apologised to Mrs E for the upsetting experience she went through. It acknowledged it could have done things better and reflected on what went wrong. It shared Mrs E’s feedback with the medical examiner, and the director and executive team who have learned from the experience.
99. The Trust’s reflection, service improvements and genuine apology sufficiently put things right in line with our Principles for Remedy. For this reason, we do not consider a financial remedy is necessary in this instance.
Personal effects 100. Mrs E complains Dartford Trust sent her father’s personal effects to the wrong house. She says she had to track them down to her neighbour’s house to retrieve them.
101. Dartford Trust explained it had mistakenly put one wrong digit on the address. It apologised for its error and acknowledged how this made an upsetting time for Mrs E even worse.
102. Our Principles of Good Administration say organisations should get things right. In this instance, Dartford Trust should have sent the personal effects directly to Mrs E. There is a clear indication of a failing here.
103. Dartford Trust’s response explained what happened and recognised how upsetting the event was for Mrs E. It understood how its actions had made things worse at an already distressing time. It apologised for the upset it had caused.
104. Reassuringly, Mrs E was able to retrieve her father’s personal items. Therefore, the impact of this event is limited and the apology appropriately puts this right. For this reason, we do not consider a financial remedy is appropriate. The nature of what happened means it is likely an isolated incident and so service improvements are not needed.
105. We hope our decision on what happened reassures Mrs E her father was looked after appropriately. We recognise how upsetting her experience must have been. Where things did go wrong the organisation responsible has acknowledged its mistakes and sufficiently put things right.