Care and treatment up to the point of transfer
21. Mrs B complains that Miss F was not given the medication and treatment she needed in a timely manner from the point of her admission to hospital. Mrs B considers this significantly affected Miss F’s chances of survival.
22. The Trust’s SI report acknowledged Miss F received sub-optimal care. It highlighted a lack of recognition of how unwell Miss F was, as well as missed opportunities to provide care and treatment, and to carry out a sepsis screen despite clear triggers. It also acknowledged that on several occasions, Miss F’s NEWS was calculated incorrectly due to the omission of a score of three for new onset confusion.
23. NG51 provides guidance on identifying and assessing those with suspected sepsis and calculating the risk of severe illness or death from sepsis. NG51 explains that a person is at a high risk of severe illness or death from sepsis if they have a suspected or confirmed infection, and NEWS of seven or above.
24. Based on the information in Miss F’s medical records, we consider it is more likely than not that she had sepsis on admission and met the high-risk criteria. Miss F had a NEWS of ten. Miss F also had a C-reactive protein (CRP) level of 77, and a white blood cell count of 20.5. CRP is a protein produced by the liver in response to inflammation. We understand that both measurements are higher than they should be and are raised when there is inflammation in the body, such as infection.
25. NG51 also provides guidance on managing and treating suspected sepsis in a hospital setting. Those who meet the high-risk criteria should:
• be immediately reviewed by the senior clinical decision maker (1.6.1) • have a venous blood test (blood gases including glucose and lactate measurements, blood cultures, full blood count, CRP, urea and electrolytes, creatinine, a clotting screen) (1.6.1) • receive broad-spectrum antibiotics without delay, and within one hour of identifying they meet any high-risk criteria, (1.6.1) • be discussed with a consultant (1.6.1) • be given an intravenous (IV) fluid bolus without delay (1.6.2) • referred to critical care for review of management (1.6.2)
26. The Trust’s deteriorating patient policy says for patients at risk of sepsis, the Trust’s sepsis screening and action tool must be used. Patients must be screened using the sepsis screening tool and managed accordingly if they have any of the following signs of deterioration: a NEWS greater than five, NEWS three in a single criterion, new or objective change in mental state, and signs of possible infection. We cannot see that the sepsis screening and action tool was utilised at any time during Miss F’s admission.
27. NICECG141 and BSG guidelines recommend antibiotic therapy is considered for patients with bleeding in the oesophagus or stomach. Furthermore, the Trust’s decompensated cirrhosis care bundle suggests looking for triggering factors leading to deterioration, such as infection. It is an essential part of sepsis care that a septic patient is escalated and responded to promptly to ensure that antibiotic therapy begins within one hour of identifying the risk level.
28. Miss F was reviewed promptly upon her arrival to the ED. The clinician planned to treat Miss F for suspected hepatic encephalopathy, upper gastrointestinal bleeding, dehydration and electrolyte disturbance.
29. Miss F had a venous blood test upon her arrival to the ED. The clinician who reviewed Miss F at 11am also requested she received IV fluids, IV pabrinex and IV vitamin K. The Trust’s SI report confirms this medication was not prescribed or administered. The omission of IV fluids at this stage meant that an essential part of sepsis care was not given within the first hour.
30. The clinician planned to discuss their findings and plans with their senior and referred Miss F to the appropriate speciality for the conditions listed in point 25 above. Our adviser confirmed Miss F’s presentation for these conditions was managed appropriately, however, no consideration appears to have been given to a possible diagnosis of sepsis.
31. Our adviser explained that when looking at Miss F’s observations and blood results in tandem, infection was a likely cause of the deterioration. For this reason, sepsis should have been considered, and Miss F should have been given antibiotic treatment within one hour of her arrival to the ED.
32. Observations were done at regular intervals throughout the day and showed a reducing trend in the NEWS. The Trust’s SI report says Miss F was confused throughout the day, and says confusion was only intermittently added onto the NEWS chart as score three.
33. When considering the accuracy of the NEWS and observations, we have taken into account they were recorded in real time and based on the clinician’s assessment of her presentation. We understand that Miss F’s underlying illness would likely have contributed to confusion throughout the day. It is possible that Miss F’s level of confusion may have fluctuated throughout the day, and we recognise this is challenging and open to interpretation by the clinician carrying out the observations.
34. We consider that from a sepsis perspective, Miss F’s care was not sufficient from the point of admission to the point of transfer (10:55am – 7:30pm). The Sepsis Manual provides guidance on ‘the Sepsis 6’. It says that delivering the Sepsis 6 within one hour is one of the most effective life-saving treatments. It involves escalating care to a senior clinician, giving oxygen if required, obtaining IV access and taking bloods, giving IV antibiotics, giving IV fluids, and monitoring NEWS. These actions should all be carried out as soon as possible, and within one hour of suspecting a patient has sepsis.
35. The clinicians treating Miss F did identify and manage her presentation for liver disease, upper GI bleeding, and hepatic encephalopathy. We can see Miss F was escalated to a senior clinician, was given oxygen, had the relevant blood tests. Whilst Miss F did receive antibiotics and IV fluids later in the day, she did not receive timely antibiotic treatment or IV fluids within an hour of her observations indicating she was at significant risk. For these reasons, we have identified a service failure.
36. We will address the impact of these failings later in our report.
Transfer
37. Mrs B complains that there were delays in Miss F being accepted for a bed, and therefore receiving the treatment she needed, due to a lack of handover and poor communication regarding her transfer between hospital sites. Mrs B also complains that Miss F was transferred with the non-emergency transport team and did not receive any active treatment when being transported between hospital sites.
38. The Trust’s ‘adult patient transfer and escort’ policy says that all patients requiring transfers must be risk assessed for clinical need, and those patients categorised as level 1, 2, and 3 will require a registered professional escort with the appropriate monitoring equipment.
• Level 1 – patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward – low risk – maintaining own airway, oxygen therapy in situ, NEWS four or less, no single NEWS of three, GCS 15/15, no mental health concerns.
• Level 2 – patients requiring more detailed observations or intervention to support (e.g., post-operative care and those stepping down from higher levels of care) – medium risk – potential risk to airway, infusions, reduced GCS, mental health concerns, NEWS five or above, single parameter of NEWS three.
• Level 3 – patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems – high risk – critically unwell patients, respiratory problems requiring ventilatory support, unstable patients requiring one organ or multi-organ support.
39. The policy says all level 1, 2, and 3 patients must have a full set of vital sign observations and NEWS score recorded within the previous 30 minutes to aid decision making as to the level of escort required. Patients who have a single parameter scoring three on NEWS and have been risk assessed as being suitable to move must have a registered professional as an escort and the relevant equipment used during the escort. A registered professional should always escort patients on transfer who have a NEWS of five or above.
40. The policy also states urgent transfers must be selected on teletracking as an urgent patient transfer as this will have an automatic higher priority than a standard transfer
41. We can see from the notes that hospital transport was booked at 3:30pm to take Miss F to the RSH. The most recent set of observations taken at 3:02pm show Miss F had a NEWS of five. At minimum, this would have put Miss F into ‘Level 2’ meaning she required transport with a health care professional.
42. Miss F’s risk level was either not recognised, or not communicated, to the hospital transport team and no urgency or medical care requirements were highlighted during the booking process.
43. At 6:12pm, an ‘inter hospital transfer information – acutely ill adult’ form was completed. This form concluded Miss F had a NEWS of four. It omitted a score for level of consciousness, but within the written information stated Miss F was confused, and notably too confused to understand the transfer and the reason for it. This likely meant her NEWS was seven.
44. This form indicates a score of four or more meant a patient could not be transferred until the score reduced, or, if there was an overriding clinical urgency. If this was the case, critical care were to be contacted, and a medical escort was required.
45. The Trust’s SI report tells us this form should not have been used, as it is not an official part of the transfer policy. Despite this, it was completed, and no action was taken in response to the NEWS, and Miss F was recorded as fit for transfer.
46. When the transport arrived at 7:33pm, Miss F’s NEWS was incorrectly calculated again. A score of two was recorded, as she was noted to be using supplementary oxygen, but this was not the case. The Trust has acknowledged the recorded NEWS omits a score of three for confusion, meaning her overall score should have been recorded as three. Whilst this shows an improvement in her condition, it would still warrant a ‘Level 2’ transfer due to this singular raised parameter.
47. With regards to communication between teams when arranging and carrying out a transfer, the following sections of Trust’s ‘adult patient transfer and escort’ policy are most relevant to this case:
• 3.1.9 – for patients transferring from an assessment area/ED or ward to ward transfer, if the bed has been declared and an attempt to ring the receiving area to handover has not been successful, the patient will be moved and accompanied by a registered professional and face to face handover given on the receiving ward.
• 3.1.10 – patients must be welcomed and handed over the to the receiving ward using the SBAR approach and supporting documentation. Ensure a full nursing handover has been given. The registered nurse is responsible for ensuring this takes place even if delegated, the receiving ward are responsible for documenting the handover.
• 3.1.11 – there must be adequate, appropriate, and timely communication between transferring and receiving staff, and with the patient, relative, or carer.
• 3.14.8 – there must be adequate and effective communication between the transferring ward/department and receiving ward/department.
48. The Trust’s deteriorating patient policy says handovers between clinical teams should include details of raised NEWS scores, or any excessively raised single indicators, and the expected monitoring or treatment plan. It explains also explains that the transferring team and the receiving ward team should work together to ensure the patient is transferred safely. The mode of transportation and need for escort must be agreed as per policy. They should jointly ensure there is continuity of care through a formal structured handover of care.
49. The Trust’s SI report goes into detail about the communication between PRH and RSH regarding Miss F’s transfer. We have also reviewed the Datix report. We will not repeat the full detail in this report, as there is no disagreement about what happened. It is evident there was a breakdown in communication and no formal handover occurred. This meant that upon Miss F’s arrival to the RSH, there was no bed available for her, and the team on the ward were not expecting her.
50. We have not seen any evidence of adequate and effective communication between the transferring and receiving wards, nor have we seen any evidence that a thorough nursing handover had been given. In the SI report, the Trust accepted that this was not how the transfer process should work and apologised that Miss F was not managed well.
51. Overall, we consider the following errors in the transfer process have amounted to a service failure:
• Instructions from the consultant gastroenterologist to transfer Miss F urgently to RSH were not followed, • Miss F’s NEWS had been calculated incorrectly at the point of transfer. It should have been recorded as a minimum of three, meaning she met the requirement for a transfer with a registered health care professional, • An accurate and meaningful assessment of Miss F’s clinical condition did not take place by the nurse who arranged Miss F’s transfer, • There was no handover from the PRH ED to the RSH AMU, resulting in a delay in Miss F being offloaded and accepted into a bed, as no bed had been allocated.
52. It should be noted that we are not critical of the decision to transfer Miss F as the consultant gastroenterologist had requested she was transferred urgently for specialist care. This care was clinically indicated. We will address the impact of the failings in the impact section of our report.
Communication with Miss F and her family
53. Mrs B complains that despite doctors deciding Miss F was unfit to make decisions for herself, her next of kin were not informed of her admission and were only contacted after she had suffered a cardiac arrest.
54. When Miss F was reviewed at 11am, she was not oriented to time, place, or person. The Trust acknowledges at this stage, a mental capacity assessment and best interests process should have been completed due to Miss F’s level of confusion. It also recognises that at this point, substantial efforts should have been made to contact the next of kin.
55. The family were not contacted until 1am the following day, after Miss F had gone into cardiac arrest. The family arrived at 2:10am and were able to be with her from approximately 4:30am onwards, by this time Miss F had been sedated and she sadly did not regain consciousness.
56. The GMC’s decision making and consent guidance explains that if a clinician suspects a patient may lack capacity to make a decision, they must assess capacity using the test set out in the relevant legislation (point 84).
57. The guidance says when a patient lacks capacity, reasonable steps should be taken to find out if the patient has previously expressed values and preferences which may be legally binding and whether someone else has the legal authority to make a decision on the patient’s behalf (point 88).
58. If there is no evidence of this, then the clinician with lead responsibility for the patient’s care should consult with those close to the patient and take into account their views about what the patient would want, when making a decision about what care and treatment would be of overall benefit to them (point 89).
59. In the Trust’s SI report, it has acknowledged that at the point the medical team carried out a mental capacity assessment and deemed Miss F not to have capacity, the family should have been contacted to be involved in the decision making regarding her care and treatment.
60. It acknowledged that it was not acceptable that Miss F’s family were not contacted until she had been transferred to the ICU, and provided an apology that every effort was not made earlier to establish contact so that Miss F could be further supported by her family.
61. We consider there was a service failure, as no formal assessment of Miss F’s capacity was undertaken, and the family were not contacted as part of the best interest’s process. We will now consider the impact of these failings.
Impact
62. Due to the failings identified in Miss F’s care, we have considered if Miss F’s death was avoidable.
63. Our adviser has explained that Miss F was very unwell at the time of admission due to a combination of hepatic encephalopathy, decompensated liver disease, hepatorenal syndrome (a complication of advanced liver disease), and most likely sepsis.
64. A Child-Pugh score is a validated tool to predict prognosis in patients with liver disease, and our adviser has explained, based on Miss F’s blood results, her score would be ‘C’ which means she carried a high mortality rate. When considering a possible sepsis diagnosis a quick sepsis related organ failure assessment (qSOFA) would give Miss F a score of two, which is associated with a 3-to-14-fold increase in in-hospital mortality.
65. This means that Miss F already had a poor prognosis and low chance of survival prior to receiving any treatment.
66. There is no disagreement that Miss F required an urgent transfer with continuous care. The Trust has acknowledged the poor communication during the transfer process contributed to the time Miss F spent waiting for a bed and meant there was a delay in her treatment being restarted.
67. Miss F was with the non-emergency transfer team for just under three hours. We consider this three-hour delay could have been avoided if there had not been a failure in the transfer process.
68. We consider this means Miss F’s deterioration would not have gone unrecognised during this time as she would have been accompanied by a healthcare professional, meaning there would not have been such a long gap without clinical care. Miss F would have had regular observations, delivery of oxygen, and a continuation of medical treatment.
69. We recognise if these steps had been taken, it would have provided reassurance to Miss F’s family that everything possible had been done to give Miss F the best chance of survival.
70. After taking this into consideration, we do not consider Miss F’s death was avoidable. Miss F was significantly unwell at the point of admission. Her initial clinical presentation and blood results indicated a very poor prognosis leading up to her having a cardiac arrest. We understand that even with optimal treatment, the eventual outcome most likely would have been the same.
71. Despite this, we recognise that opportunities were missed to provide Miss F with an optimal level of treatment. We recognise this has caused Mrs B and her family significant distress, as they are left with an uncertainty of whether the outcome could have been different.
72. With regards to the impact of the poor communication, the family were only called once Miss F was unconscious, and this meant they missed the opportunity to be there with her whilst awake, and to be there in her final conscious hours to provide valuable support and advocate for her. We recognise this caused considerable distress for the family.
73. We understand that the family were very upset to learn that Miss F was alone whilst being so confused, disoriented, and agitated. They felt this deprived Miss F of the comfort, support, and familiarity of her family whilst conscious, scared, and confused.
74. We have considered what steps the Trust has already taken to put things right for Miss F’s family. Our Principles for Remedy say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.
75. We can see that the Trust has acknowledged several failings in Miss F’s clinical care and in the transfer process within the SI report, and that it has given due consideration to how this impacted Miss F’s presentation and deterioration.
76. With regards to poor communication with the family, the Trust has acknowledged what went wrong, the missed opportunities this caused, as well as the impact this has had on the family. The Trust has also provided an apology for this failing in communication, and the impact it had.
77. We recognise the Trust has taken steps to acknowledge what happened in Miss F’s care. We do not consider it has done enough to provide Mrs B with a sincere and meaningful letter of apology, or to make amends, for the failings that occurred, the impact these failings had, and how this has continued to impact the family. We will outline our recommendations relating to this in the next section of our report.
78. With regards to identifying learning and using it to improve services, we are aware several changes had already been made, prior to the SI report recommendations, which were relevant to this case, including: • a review of the inter-hospital transfer policy, • deteriorating patient and escalation stickers and policy both introduced to the ED, along with education which highlighted to staff that patients who are young can compensate for longer, • a new SBAR handover procedure introduced and education given • ED practice education facilitators to ensure all staff are compliant with NEWS2 training, • Reception staff instructed to confirm patient and next of kin details in full on arrival, and nursing staff to confirm these details once a patient is in their area.
79. We can also see recommendations were made in the SI report to:
• remove out-of-date Mental Capacity Act documentation and inter-hospital transfer forms, • raise awareness of the importance of completing Best Interests paperwork when a patient lacks capacity and contacting the next of kin at this stage to support with decision making, • when new confusion is identified, to record a score of three on a patient’s NEWS, which will trigger a sepsis screen and appropriate escalation, • share the report with the quality matron to ensure it feeds into the new hospital transfer policy, which will include a clear escalation model to support staff from the transferring wards if there are any communication difficulties • include doctor-to-doctor handovers in the interhospital transfer policy, as well as an updated checklist, • ensure staff who were directly involved in Miss F’s care complete a piece of reflection and reflective discussion regarding their role and what went wrong, • highlight the SI report to the executive team to inform discussion about overcrowding and lack of staffing, and the impact it had in this case.
80. We consider the Trust has taken fair and proportionate steps in line with these Standards to improve the service it provides. For this reason, we will not be making a recommendation for service improvements.