11. Ms C complained that the Trust failed to provide appropriate treatment for her mother’s respiratory issues whilst she was in hospital between 13 and 16 March 2023.
12. The Trust’s response to Ms C’s complaint said there was no requirement for Mrs B to have a CPAP machine at that time. Her observations (measurements of the body’s basic functions: temperature; respiratory rate; pulse; blood pressure; blood oxygen saturation) were within acceptable parameters. Her oxygen saturation levels were improving. Therefore, Mrs B did not require additional support by way of oxygen therapy. This, however, provides a contradictory position to the Trust’s own Structured Judgement Review, which found the care provided to Mrs B was inadequate.
13. NICE guidelines on chronic obstructive pulmonary disease (COPD) are applicable to Mrs B’s care. These guidelines require clinicians to:
‘1.3.29: measure arterial blood gases (ABG)… Repeat arterial blood gas measurements regularly.’
‘1.3.30 Use non-invasive ventilation [NIV – CPAP is a form of NIV] as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy.’
14. The Imperial College guidelines outline an example of requirements for adult NIV as being potentially reversible Acute Hypercapnic Respiratory Failure, with obesity and pH (blood acidity level) of less than 7.35 and PaCO2 (blood concentration of carbon dioxide) of at least 6.5. (Respiratory acidosis is a condition where lungs cannot remove carbon dioxide efficiently, leading to high levels in the blood. It is measure by pH level of the blood and a person is acidotic if it is below 7.35.)
15. NICE quality statement 7: None-invasive ventilation states: ‘Noninvasive ventilation is used to treat persistent hypercapnic ventilatory failure and acidosis during an exacerbation of COPD, when a person's arterial blood gases (especially the pH and carbon dioxide levels) are not responding (or worsening) despite optimal medical management’.
16. The records show Mrs B’s pH was 7.22 on 13 March and 7.29 on 14 March. Her PaCO2 was 9.85 on 13 March and 7.88 on 14 March. Therefore, at this time she met the requirements for NIV therapy in line with the guidance. This means the Trust should have considered providing Mrs B with assisted ventilation in the form of NIV.
17. The records show the Trust assessed Mrs B’s NIV requirements on 13 March at 11.06pm. This record notes ‘One further ABG, if acidotic [had an acidic blood pH] then NIV’. A record a few hours later at 1.54am on 14 March noted Mrs B did not want an ABG at that time. The record says ‘improvement but still acidotic… As improving then not for NIV currently, will do a further ABG at 06:00’. Therefore, doctors were planning to review Mrs B again with a further ABG, before deciding whether to provide assisted ventilation via NIV.
18. There is no record that clinicians conducted a further ABG to establish whether Mrs B was still acidotic. We saw nothing in the records that suggests her acidosis improved. Therefore we consider Mrs B is likely to have required NIV treatment, but the Trust did not provide this.
19. The Trust conducted a structured judgement review (SJR) following Mrs B’s death. An SJR is a review undertaken after a patient’s death, which looks at the quality of care they received. This review concluded the Trust made errors with its management of her respiratory problems, in line with the analysis above. One of the issues identified was that Mrs B should have had a NIV device to help her with breathing. The review says may have reduced her chance of death. The review outlines learning points from this issue that ‘patients should continue on their own treatments when admitted to hospital, including home CPAP/NIV unless contraindicated’.
20. Therefore, the evidence shows the Trust failed to appropriately manage Mrs B’s respiratory illness whilst she was in hospital, as it did not provide NIV treatment despite indications it should have.
21. Regarding Ms C’s complaint that the Trust failed to transfer her mother to a respiratory ward, we identified the Trust did not provide the appropriate respiratory treatment regardless of which ward she was on. There is no indication that Mrs B needed any treatment that could only be provided on the respiratory ward.
Duty of Candour
22. All NHS organisations have a responsibility to be open and transparent with patients and their family members. This is called the duty of candour. It is laid out in section 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
23. Section 20 outlines: ‘As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a registered person must notify the relevant person that the incident has occurred’.
24. In this context, a ‘notifiable safety incident’ means ‘any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in— (a) the death of the service user, where the death relates directly to the incident rather than to the natural course of the service user’s illness or underlying condition, or (b) severe harm, moderate harm or prolonged psychological harm to the service user’.
25. In this case, the Trust identified failings in its own care, which they say could have potentially increased Mrs B’s chances of death. In our view this amounts to a ‘notifiable safety incident’ in line with Section 20. As such the Trust had a duty of candour and should have informed Ms C about their failure to deliver appropriate care.
Impact
26. The Trust’s own SJR outlines respiratory acidosis with pH<7.25 is associated with poor outcome and explains its failure to provide an NIV to Mrs B could have increased her chances of death. The report assigns an ‘avoidability score’ which provides its judgement as to the likelihood that death could have been avoided in this case. The avoidability score outlined is 4, which represents ‘possibly avoidable, but not very likely (less than 50:50)’. Therefore, the Trust’s position is that it could possibly have prevented Mrs B’s death if it provided the appropriate respiratory treatment. However, the chances of this were small.
27. Our adviser says it is possible that death was made slightly more likely if Mrs B remained in respiratory failure, which could have been properly treated with NIV. The failure to do the further blood gas test meant there was no consideration for additional treatment particularly of NIV. It is possible that Mrs B remained acidotic with respiratory failure. If this were the case then it was mild; her observations were not worryingly abnormal and she was noted to be clinically stable. Her death did not appear to be related to progressive respiratory failure; it was sudden. However it is possible that the terminal event (possibly cardiac or stroke) was made a little more likely if she remained in respiratory failure. We consider the SJR conclusion were reasonable in that there was a small possibility that Mrs B’s death may have been avoided if her respiratory failure had been properly assessed and treated.
28. The Trust has demonstrated learning from this incident. However, The Trust’s response does not remedy this, as it defended its actions, instead of accepting the errors its own report identified. The Trust has explained to us that it did not share these findings with Ms C because it does not share SJR’s with family members as standard. As such, Ms C was not provide with any information about the Trust’s findings.
29. The Trust did not provide an adequate explanation to Ms C about the problem it identified with its provision of care. There was no communication about the steps the Trust has taken to prevent this occurring again. This is not in line with the Trust’s duty of candour. Therefore, the Trust’s actions in identifying failings did not go far enough to remedy Ms C’s complaint.