Complaint about being told to attend the ED
14. Mrs G thinks it would have been more appropriate for a doctor to see her son in the podiatry clinic rather than in the ED because of his immune system. The Trust said signposting to the ED was appropriate because of the risks of severe infection in Mr M’s foot.
15. The records say the podiatrist was concerned the infection in Mr M’s foot had got worse despite oral antibiotics. They felt he needed to see a doctor to but there were none available in clinic, hence the decision to tell him to attend the ED. When Mr M got to the ED he was admitted and needed intravenous antibiotic treatment for his skin infection.
16. The NICE CKS says people with cellulitis should be sent to hospital if they have another health problem that may complicate their recovery, or a suppressed immune system. They should also be referred if there are signs the infection may be serious, or it is not responding to oral antibiotics.
17. This applied to Mr M, so we think it was appropriate for him to be told to attend the ED. In addition to this, there were no doctors available in the podiatry clinic so it would not have been possible for a review to take place there. We understand why Mrs M preferred her son not to be sent to hospital. However, we saw no indication anything went wrong here.
Complaint about not being isolated
18. Mrs G says her son should have been isolated from other patients and put in a side room because he had a suppressed immune system following a kidney transplant in 2011.
19. The DHSC guidelines says people who have had a kidney transplant are considered ‘clinically extremely vulnerable’ to COVID-19, which means there is a higher risk of becoming seriously ill. The PHE guidelines say individuals ‘clinically extremely vulnerable’ to COVID-19 will need protective measures to protect from COVID-19, depending on their medical condition and treatment, such as isolation in a side room.
20. Therefore, we can see Mr M was the type of person who should be considered for placement in a side room.
21. The PHE guidance indicates availability of side rooms should be taken into consideration when deciding where to place patients.
22. The Trust has not documented in Mr M’s records any consideration of his need for a side room, or the availability of a room. However, this may be because decisions about who to put in side rooms was being made in a dynamic way for all patients in the department and therefore not documented in each individual’s records. We have therefore had to rely on the Trust’s explanation in its complaint response.
23. The Trust has said there were no rooms available. We know that during this period NHS trusts were under immense pressure and side rooms were very limited due to the number of infectious COVID-19 patients needing isolation from others.
24. We note the Trust says the specialist renal team caring for Mr M said he would not have needed to be isolated due to his immunosuppressed status. We also note the Trust has said his white cell count and neutrophils were normal. These are blood test markers which show how well a person’s immune system is working.
25. We agree with Mrs G that it would have been better for Mr M to be in a side room. However, considering the above, we cannot say the Trust got anything seriously wrong when it did not put Mr M in a side room if none were available and it felt he was not a priority over actively infectious COVID-19 patients based on his normal blood results at the time.
Complaint about insulin on 31 July
26. We saw no indication Mr M went without insulin on 31 July. The records show staff regularly monitored his blood sugars, and Mr M regularly had insulin throughout the entire day. Some of this was his own supply, and some was prescribed by the ward.
27. We understand from Mrs G’s account that her son’s wife attended the hospital that evening to drop off more of his own supply of insulin. We cannot see any evidence staff were dependent on this or asked for her to come in, or that Mr M was left without insulin. Therefore we have seen no indications anything went wrong here.
28. To offer further reassurance to Mrs G, we also cannot see any indication Mr M’s blood sugars were dangerously high.
29. Infection can cause blood sugars to rise. Mr M had elevated blood sugars at the start of the day, and these came down when his insulin prescription was altered. Our adviser explained it is not unusual for blood sugars to be as high as Mr M’s in these circumstances, and his levels were not dangerously high.
30. They would only be considered dangerous if they were accompanied by some specific altered blood test results. Our adviser says there was no evidence of this. We hope this reassures Mrs G.
Complaint about steroid injection
31. Mrs G says her son’s specialist kidney team from another NHS Trust had prescribed him a steroid injection to take if he had an illness. Mrs G says her son had this injection with him on the ward, but the staff would not allow him to have it.
32. The only reference to the injection in Mr M’s records is an entry from the ward pharmacist on 3 August, who documented that Mr M had been expecting a hydrocortisone (a type of steroid) injection when he was admitted.
33. We could not see any documentation that staff were aware of the injection before this, or that Mr M had it with him and staff told him not to take it. There is a detailed medication history taken from his GP records and this does not mention the injection, but his usual oral dose of steroids is included. We can see the Trust prescribed oral steroids at an increased dose due to his infection, and additional steroids were prescribed 5 days later.
34. There is no other evidence about the injection for us to consider, so we cannot establish whether staff did or did not know about it, or whether they told Mr M he could not have it.
35. We considered the dose of steroids the Trust gave to Mr M and whether this was in line with the steroids guidelines. Although these guidelines are undated, they apply to the period of time we have considered. Our adviser explains they formalise widely accepted practice at the time of events and there are no other guidelines from this time.
36. According to these guidelines, it is usual practice to the double the dose of steroids for people who are acutely unwell. In Mr M’s case, the Trust doubled his usual dose of prednisolone (another type of steroid). We therefore cannot see indications anything went seriously wrong here.
Complaint about self-administration of medication
37. Mr M usually took his medication via prepackaged medication trays (called a ‘nomad system’). Mrs G is unhappy the Trust did not allow him to use these when he was in hospital.
38. We cannot see any mention in the records that Mr M had specifically asked to be able to self-administer medication, but we accept Mrs G says this would have been her son’s preference.
39. In its complaint response the Trust said ‘it is standard practice while in hospital that nomad systems are stopped, and patients are given their medications by the ward staff with support from pharmacy’. It explained this is because medications and doses can be changed, and people with access to their nomad system could inadvertently take the wrong medicine.
40. Our adviser explained in an acute setting, where it is important that someone is receiving the correct medication at the correct dose, it is acceptable to not allow them to self-administer. Our adviser says an exception may be for people with diabetes, and we can see staff did allow Mr M to administer his own insulin when he needed it.
41. This was in line with the GMC guidance which says doctors must provide effective treatments that serve patient’s needs and are compatible with any other treatment. This cannot be done if someone is self-administering other medication that is subject to change. We hope this explanation gives Mrs G some reassurance.
Complaint about delays in COVID-19 testing
42. When the Trust investigated Mr M’s death, and responded to Mrs G’s complaint, it accepted it made a mistake here and offered an apology. It explained that in line with its local procedures, Mr M should have been retested for COVID-19 on day 3 of his admission (2 August) but this did not take place until 5 August.
43. The Trust also accepted and apologised for delays in the COVID-19 swab being sent for testing. It is difficult to see how long it took, but it appears the laboratory did not receive it until 7 August, and the result was available later that day. We can see the first mention of the positive result was when someone reviewed Mr M in the early hours on 8 August.
44. We cannot say what the result of the COVID-19 swab would have been had it been done on 3 August. However, the delay in testing the swab taken on 5 August meant there was an approximately two day delay in Mr M starting COVID-19 treatment. Mrs G is concerned this reduced her son’s chances of survival. We considered this further.
45. The DSHC guidance explains people with serious medical problems who are vulnerable to COVID-19 are at higher risk of having severe COVID-19. This sadly means there is a higher risk of death for people like Mr M.
46. Our adviser explained in Mr M’s case, starting COVID-19 treatment sooner would not have made enough of a difference to positively impact his chances of survival.
47. After discussing Mr M’s case with kidney specialists, the Trust prescribed tocilizumab to treat his COVID-19. This is type of medication which suppresses the immune system to help tackle severe inflammation in the body. We note this was the only COVID-19 treatment available to Mr M, aside from further steroids.
48. The tocilizumab commissioning policy explains tocilizumab should be used with caution in patients who already have immune system suppression (which was the case for Mr M) as there is a risk it may be even less effective. The Trust and renal specialists felt this risk was necessary to accept as there were no other treatment options for him.
49. Our adviser explained the tocilizumab would not have had better chances of working if it had been prescribed sooner. We therefore cannot see any evidence that the outcome would have been any different for Mr M if the Trust had not delayed in COVID-19 testing and had diagnosed it sooner.
50. We understand why Mrs G was very concerned about how her son died, and we do not underestimate how deeply she has been affected by her loss. We hope the explanations provided about Mr M’s survival chances, whilst incredibly sad, bring her some comfort and reassurance that the outcome would not have changed even if the Trust had not made a mistake.