NTH Trust
15. Mrs R says doctors should have diagnosed the bleed on her mother’s brain during her admission to Hartlepool Hospital in September 2022. She understood the bleeding followed the fall she had a few weeks earlier.
16. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.
17. The Head Injury Guideline when adults have sustained a head injury clinicians should arrange a CT scan if a patient has any of a list of risk factors.
18. The clinical records for the admission from 8 September 2022 make no reference to Mrs E having any symptoms that could be interpreted as being due to a head injury. Her main complaint was that she had been incontinent of urine for around two weeks following a fall. She also had back pain but no signs of any injuries to her brain or spinal cord.
19. Doctors arranged an MRI scan of Mrs E’s lower back. The MRI scan showed a compressed fracture to the lower back which did not need any surgical intervention. They did not consider she was confused. They planned to review her at a spinal clinic in four weeks.
20. The Medical Adviser said the only reasons to repeat the head scan that had taken place after the fall would be signs of a new neurological problem or a further head injury. This was not the case for Mrs R during her admission in September 2022.
21. We recognise Mrs R believes the bleed on her mother’s brain was present during September 2022. We have seen no clinical evidence to support this. We note the record of the coroner’s inquest indicates it was Mrs R’s high blood pressure that led to the bleeding rather than the fall she had on 23 August 2022.
22. The clinical records show doctors carried out adequate assessments of Mrs E’s injuries and arranged the investigations and treatment she needed. There was no need for them to investigate Mrs E’s head at that stage. We find doctors followed Good Medical Practice and the Head Injury Guideline.
County Durham Trust
Nutrition
23. Mrs R says there was a delay in giving her mother a feeding tube. She says this should have happened before the fifth day of her admission. She says there was then a delay of two days when her mother pulled the tube out and a further delay in providing gloves to prevent her pulling the tube out. Mrs R says nurses used the feeding tube when her mother was lying flat and that this caused problems for her. She says they failed to provide regular nutrition. She believes they ‘starved’ her mother, and this affected her ability to recover.
24. Clinicians should have followed the Nutrition Guideline. It says healthcare professionals should consider providing nutrition support for people at risk of malnutrition. It refers to considering enteral (using a tube) or parenteral (delivering nutrients directly into the blood – TPN feeding) nutrition support for people who need it. It also recommends referrals to dieticians and specialists who can carry out swallowing assessments, such as speech and language therapists (SALT), when necessary.
25. The Nutrition Guideline says healthcare professionals should consider tube feeding for people who are malnourished or at risk of malnutrition and who have inadequate or unsafe oral intake. Tubes need to be inserted by healthcare professionals with the relevant skills or training.
26. The clinical records show the SALT team reviewed Mrs E on 11 November 2022. They noted it was not safe for her to swallow at that point and that a feeding tube should be considered. A doctor met with the family the same day and noted they were happy for clinicians to try using a feeding tube.
27. We can see that clinicians inserted a feeding tube for Mrs E on 12 November 2022. This was three days from her admission to North Durham Hospital. Unfortunately, she appears to have pulled the tube out during the night and a tube was inserted again the following day. Mrs E again pulled out the tube which was reinserted later that day with a bridle attached. A bridle is used to reduce the chance of a tube being dislodged.
28. A dietician reviewed Mrs E on 14 November 2022. They said it was not safe for Mrs E to eat because of the risk of aspiration. They planned to continue with feeding and requested mittens to prevent Mrs E pulling the tube out again. There is no record of when mittens were actually provided, but no further records to show Mrs E pulled the tube out again.
29. Over the following days we can see that Mrs E received nutrition from the feeding tube. There were regular reviews from dieticians and SALT, and we can also see that diabetic specialist nurses were monitoring Mrs E’s intake.
30. The records show clinicians decided to stop using the feeding tube on 26 November 2022. This was because they were concerned the tube could have been affecting Mrs E’s breathing. Mrs E’s family was upset about this, and clinicians explained the reasons to them. The tube was in use the following day and continued until 29 November when clinicians removed it in preparation for Mrs E’s discharge from the hospital.
31. The Nursing Adviser told us the records show Mrs E received adequate nutrition during her admission to North Durham Hospital. Nurses recognised she needed support in this respect. They referred to SALT on 11 November, and they recommended a feeding tube which was in place by the next day. Dieticians were also involved within five days of her arrival at the hospital.
32. There is no national guidance specifying timescales for providing a feeding tube. We can see no evidence to suggest there was any delay in this respect. There are also no references in the clinical records to the feeding tube not working properly because of Mrs E’s position in bed. As we have said above, we are persuaded the clinical records are accurate and we would expect any concerns about Mrs E not receiving nutrition to have been documented.
33. The Nursing Adviser told us mittens are not usually provided unless they are shown to be necessary. Safety mittens are considered to be a form of restraint and can only be used if they are in the patient's best interest. This would only be known once a patient has made repeated attempts to remove a feeding tube. Mrs R recalled mittens took several days to arrive. It is not possible for us to know exactly when this happened. The clinical records suggest that there were no problems with Mrs E attempting to remove the feeding tube after 14 November 2022. We cannot say there was a delay in providing mittens.
34. We find the clinicians at North Durham Hospital followed the Nutrition Guideline when supporting Mrs E with her nutrition. We recognise Mrs R has strong views about this. We can see no evidence that nurses failed to provide regular nutrition or delayed supporting Mrs E.
Pain relief
35. Mrs R complains that clinicians did not assess her mother’s pain regularly enough or provide her with appropriate pain medication. She says her mother was crying because of her pain. She also recalled an incident when she asked a nurse to provide pain relief for her mother and was ignored. She says it was only when her son raised concerns that staff set up a paracetamol drip, over three hours later.
36. The Patient Experience Guideline says healthcare professionals should appreciate the importance of assessing and managing pain. It says they should not assume that a patient’s pain relief is adequate. They should use a pain scale if necessary and provide pain relief and adjust as needed.
37. The Nursing Adviser told us there is evidence that nurses assessed Mrs E’s pain during her admission. They used the FACES system, which is a pain scale as indicated in the Patient Experience Guideline. This is used for people who have cognitive impairments to help them explain their pain level using pictures of faces ranging from very happy to very sad. The clinical records do not refer to any incidents when Mrs E complained of pain. The FACES scores do not indicate she was in severe pain. Nurses also completed other pain assessments based on their observations, and these did not show she had unresolved pain.
38. The clinical records show doctors prescribed paracetamol for Mrs E from 10 November 2022 onwards. This could be given intravenously up to four times a day if needed. Doctors also prescribed codeine from 15 November, which Mrs E took from that date onwards. We can see there were occasions when clinicians gave Mrs E paracetamol for pain. These were on 10, 11, 14, 21 and 23 November. There are several other records noting times when Mrs E did not have any pain or discomfort.
39. By 26 November 2022 the clinical team had established that the focus was on keeping Mrs E comfortable. They prescribed palliative medication, which included morphine. They gave Mrs E morphine on 26 and 30 November. The Nursing Adviser told us it is a matter of clinical judgment for an individual nurse about whether to administer pain relief.
40. We have no reason to doubt Mrs R’s recollection that her mother was in pain at times. There is evidence in the records to support this. We appreciate this must have been distressing for her to witness. We find nurses monitored Mrs E’s pain. They ensured she received appropriate pain relief. They followed the Patient Experience Guideline.
Anti-seizure medication
41. Mrs R recalled that a nurse gave her mother anti-seizure medication. She asked why doctors did not prescribe this sooner if it was necessary.
42. Good Medical Practice says doctors should adequately assess patients and arrange timely treatment for them.
43. The clinical records do not indicate that Mrs E needed anti-seizure medication before she attended North Durham Hospital. On 20 November 2022 a nurse noted Mrs E was blinking rapidly and her limbs were convulsing. The nurse called for assistance and administered intravenous medication, levetiracetam (used to treat seizures for people who have epilepsy), which appeared to resolve the seizure. Doctors gave her this medication intravenously throughout the remainder of the admission.
44. The Medical Adviser said doctors would not prescribe anti-seizure medication before someone had a seizure. There is no evidence Mrs E had a seizure before 20 November 2022.
45. We find clinicians gave Mrs E appropriate medication when she needed it following the first seizure. They followed Good Medical Practice.
Communication
46. Mrs R says she understood her mother was to be transferred to a different hospital for surgery on the brain bleed. Instead, doctors told her the transfer was not happening because surgery was not appropriate. She says communication from doctors was confusing and often delayed. She says they gave conflicting information to the family about her mother’s prognosis.
47. Good Medical Practice says doctors must communicate effectively. It says they must be considerate to those close to the patient and be sensitive and responsive in giving them information, advice, or support.
48. In its complaint responses the Trust has detailed all the points at which clinicians discussed Mrs E’s care with her family. We have decided not to repeat that information here. But we can see those conversations are documented in the clinical records.
49. Early on 10 November 2022 a doctor reviewed the results of a CT scan of Mrs E’s head. They noted there was a large haemorrhage and planned a referral to the local neurosurgery team.
50. Later that morning Mrs R met with two of the doctors caring for her mother. They explained that a large bleed or stroke had been found, and this had led to aspiration pneumonia developing. They explained that 72 per cent of people affected by this type of stroke can die within one month and the pneumonia made this even more likely for Mrs E. The doctors said she was too unwell to transfer to the different hospital for surgery as had originally been planned.
51. The Medical Adviser told us that the communication by doctors and nurses was excellent. There is clear evidence of regular, sensitive, and very detailed discussions with reiteration of the key points. Doctors made several attempts to explain the severity of Mrs E’s illness to family members.
52. We can see no evidence of any confusing or contradictory communication from the accounts doctors included in the clinical records. They appear to have provided timely updates to the family and to have been clear about the decline in Mrs E’s health.
53. We find the doctors followed Good Medical Practice in their communication with Mrs E’s family. We appreciate how distressing it must have been for Mrs R around this time given the sudden deterioration in her mother’s health. We cannot see any evidence doctors fell below the relevant standards relating to communication.
DNACPR
54. Mrs R says doctors did not communicate their decision not to resuscitate her mother if she had a cardiac arrest or stopped breathing. She recalled a doctor saying her mother had only three days to live on 10 November 2022 but did not recall any reference to a DNACPR. She understood that once her mother got through those three days, she stood a good chance of survival. She says doctors put the DNACPR order in place without the family’s knowledge.
55. The Resuscitation Guideline says, even when CPR has no realistic prospect of success, clinicians should explain the need for a DNACPR decision or those close to a patient who lacks capacity. It says it is not necessary to obtain consent for a DNACPR decision from the patient or those close to them in these circumstances. The patient and family do not have a right to demand treatment that is clinically inappropriate, and healthcare professionals have no obligation to offer such treatment.
56. The Resuscitation Guideline says it is essential to that decisions about CPR are made and understood clearly by all those involved. There should be clear, accurate, honest and timely communication with the patient and those close to them. Healthcare professionals should clearly document these discussions and decisions.
57. The clinical records show there were detailed discussions throughout Mrs E’s admission to North Durham Hospital.
58. We have already referred to the discussion Mrs R had with two doctors on 10 November 2022. Part of the discussion related to DNACPR. The doctors explained how they would continue to provide active treatment for Mrs E. However, if her condition deteriorated, they would consider palliative care, which they called a ‘gentle approach.’ The doctors noted there was likely to be a terminal event approaching. They said they discussed resuscitation, and the family understood about the diagnosis and poor prognosis.
59. Doctors completed the DNACPR order on 10 November 2022. They noted the reason for this was that Mrs E was frail, and CPR would not be in her best interests. They highlighted there had been a discussion with family members.
60. On 18 November 2022 there was a further discussion about DNACPR. Mrs R was concerned that the DNACPR order was in place. A senior nurse explained that this was because if Mrs E’s heart or breathing stopped it would not be of any benefit for her to try CPR. The nurse was clear that this did not mean other treatment would stop.
61. Two doctors met with family members again on 21 November 2022. They again explained the reasons for the DNACPR order. Over the following days there were several other conversations showing that doctors explained that Mrs E was becoming more unwell.
62. The Medical Adviser told us the documentation suggests doctors recognised Mrs E’s family was struggling with the information given. They made attempts to help them to understand and discussed what was happening at various stages. The discussions were carefully documented and were clearly detailed and sensitive.
63. We find doctors followed the Resuscitation Guideline. The DNACPR decision was a medical decision, and doctors did not need consent from Mrs E or permission from her family. There is no evidence to support the claim that the DNACPR order was made without the family’s knowledge. The records show healthcare professionals had discussions with the family about why the order was put in place. The discussions were appropriately documented.
COVID-19
64. Mrs R recalled that her mother developed a bad cough on the ward. She said other patients were also coughing. She asked staff whether her mother had COVID-19 and was told she had tested negative for it. She says her mother was found to have COVID-19 when she left the hospital. This meant district nurses could not attend, and her death was not as comfortable as it should have been.
65. The NHS England Guidance instructed all NHS leaders to stop routine COVID-19 testing for patients who did not have any symptoms from 31 August 2022. The Trust said its policy at the time was not to test people for COVID-19 before discharging them from hospital, if they had no symptoms.
66. There is no evidence in the clinical records that clinicians at North Durham Hospital suspected Mrs R had COVID-19 on 30 November 2022. There is no reference in the clinical observations to Mrs E having a cough. Neither is there any record that clinicians tested her for COVID-19.
67. The Medical Adviser said COVID-19 testing would have had no clinical benefit for Mrs E. She was already receiving end of life care and there would have been no other treatment available for her.
68. We find clinicians followed the NHS England Guidance when they did not test Mrs E for COVID-19 before she left North Durham Hospital.
Discharge
69. Mrs R says clinicians assured her that everything had been put in place for her mother to receive care at home. She says this did not happen which meant her mother was left without the support she needed, when she left North Durham Hospital on 30 November 2022, and she did not get access to nutrition and fluids.
70. The Discharge Guideline explains what healthcare professionals should put in place for people who need end of life care when discharging them from hospital. It says they should offer people general and specialist palliative care services. It says they should ensure continuity of care for people and ensure that a GP or community nurse phones or visits the patient within three days of their discharge.
71. The clinical records show clinicians at North Durham Hospital discussed the possibility of discharging Mrs E at a meeting with her family on 26 November 2022.
72. Clinicians completed a discharge letter for Mrs E’s GP. This explained that the plan was to arrange support from district nurses at home. There would also be palliative and supportive calls from the palliative care team. A syringe driver was in place which would be reviewed each day by a nurse.
73. On 29 November 2022 a palliative care doctor reviewed Mrs E. They arranged for the syringe driver to continue and adjusted her medication. They also planned for oxygen and a hospital bed. These were all in place by the time Mrs E arrived home.
74. A nurse on the ward contacted the district nurses on 29 November 2022. They agreed to visit Mrs E the next day. The district nurses said they would refer to community Macmillan nurses and the Marie Curie team for further support. The nurse discussed this with Mrs R who said she was happy with the plan. The records show Mrs E had access to oxygen and that the syringe driver was available when she left the hospital.
75. Community nurses visited Mrs E on 30 November 2022. They ensured there was enough medication for the syringe driver. A GP had a video call with the family the following day. The GP explained Mrs E was too unwell for PEG feeding at that stage. The nurses did not provide intravenous fluids because she was approaching the end of her life.
76. The Nursing Adviser said the evidence in the records indicates that clinicians appropriately assessed Mrs E’s needs. They ensured she had the support she needed following her discharge from the hospital.
77. We find the clinicians at North Durham Hospital followed the Discharge Guideline. They ensured appropriate referrals were made to relevant services. They provided the equipment and medication she needed. We appreciate this was a difficult time for Mrs R and her family. We can see no evidence that clinicians from North Durham Hospital fell below the relevant standards when making these arrangements.
Conclusion
78. We have seen no evidence clinicians at either of the organisations failed to provide appropriate care to Mrs E in relation to the issues we have investigated. Clearly, these events were incredibly distressing for Mrs R. We cannot say the deterioration in her mother’s health, or the distress her family experienced, were due to failings by either trust.
79. We recognise this decision is likely to be upsetting for Mrs R. We hope she is reassured that we have carefully considered all the evidence and have found that her mother’s care did not fall below the relevant standards. We do not uphold her complaint.