Antibiotics 22. NICE Guideline NG138 (community acquired pneumonia) outlines that antibiotic treatment should be provided for five days. At the five-day mark this should stop unless microbiological testing suggests a longer course is needed, or the person is not clinically stable.
23. Indicators of clinical instability, as outlined in this guidance, include:
• the person has had a fever in the past 48 hours • systolic blood pressure (top number in a blood pressure reading) less than 90 • heart rate of more than 100 beats per minute • arterial oxygen saturation (percentage of oxygen in the blood) less than 90%.
24. Doctors should assess whether a patient is clinically stable, after antibiotic treatment, in line with Section 15 of the GMC’s Good Medical Practice guidelines.
25. On 31 May Mr A’s vital signs did not show any clinical indicators of infection. The Trust used the National Early Warning Score 2 (NEWS2) to calculate his illness severity based on his vital signs.
26. Mr A’s NEWS2 score was zero on 31 May, meaning his vital signs were all within the expected ranges. His blood tests also showed that his CRP (inflammatory marker that can rise due to infection) had reduced significantly.
27. As of 31 May, Mr A had been prescribed antibiotics for slightly longer than recommended. He also had none of the signs of clinical instability outlined in NICE guideline NG138 and his NEWS2 score was zero. This meant there were no clinical indicators of infection at this point. It was, therefore, appropriate and in line with NICE guideline NG138 to stop his antibiotics on 31 May.
28. We also considered his family’s concerns about taking sputum samples. This includes whether there was any indication to take samples, and whether doing so could have changed the decision to stop antibiotic treatment on 31 May.
29. NICE guideline NG138 recommends taking sputum samples only if signs and symptoms of infection remain after initial antibiotic therapy. Mr A was clinically stable after the first course of antibiotics, and so testing samples of his sputum was not indicated by the national guidelines.
30. Mr A’s family are also concerned that he went on to be diagnosed with hospital acquired pneumonia on 9 June. They say he continued to show signs of infection that were overlooked between 31 May and 8 June.
31. We reviewed Mr A’s clinical presentation between these dates. His NEWS2 score remained consistently low during this period, and his blood results did not indicate an infection may be present.
32. Mr A presented with confusion on 2 June, and the Trust reviewed his condition. His blood results showed elevated sodium levels, and the doctors attributed his confusion to this. Our physician adviser confirmed that based on the overall clinical picture, this was appropriate as there were no clinical signs of infection at that time. This was in line with the GMC’s Good Medical Practice guidelines.
33. The first date on which clinical indicators of infection became apparent was 9 June, when Mr A’s NEWS2 score and CRP increased. A chest X-ray was completed that day, and he was diagnosed with hospital acquired pneumonia. Based on the available medical evidence, the doctors acted quickly to identify this infection when the clinical picture changed. There is no evidence the Trust overlooked ongoing signs of infection prior to this diagnosis being made.
Fluid monitoring 34. In line with NICE guideline CG138 (patient experience in adult NHS services) the nurses should have ensured Mr A’s nutrition and hydration needs were adequate at all times. The staff should also have ensured his needs were monitored and accurately recorded, in line with the NMC Code.
35. On admission to hospital, Mr A had been retaining fluid due to his heart failure (known as congestive heart failure). Excess fluid can cause a lot of discomfort, breathlessness, reduced mobility, and adversely affect liver and kidney function. When a patient presents with congestive heart failure, doctors will usually try to remove some of this excess fluid and recommend a fluid intake restriction.
36. On 22 May the ward consultant assessed Mr A’s needs and prescribed diuretic medications. They documented Mr A’s fluid intake should be restricted to 1.5 litres per day. This meant the nursing team should have commenced monitoring his fluid intake and consistently recorded this on a fluid balance chart.
37. Our nursing adviser reviewed Mr A’s fluid balance records and noted that whilst fluid balance charts were commenced on 22 May, these were inconsistently completed. The records for May indicate that the nurses consistently recorded fluid intake far below 1.5 litres, with just one day documenting sufficient fluid intake. No data was recorded for 25 May, and it is very concerning that only 150mls of fluid intake was recorded for 24 May.
38. The evidence shows that between 22 May and 1 June, the nurses either failed to accurately record Mr A’s fluid intake, or failed to ensure his fluid intake was adequate. Failure to accurately record his fluid intake does not align with the NMC Code; and a failure to ensure adequate fluid intake falls short of NICE guideline CG138.
39. It is difficult to know, with hindsight, whether the nurses failed to ensure Mr A’s intake was adequate or failed to record his intake accurately. Irrespective of which of these omissions took place, this amounts to service failure and we have considered the impact this likely had.
40. Our geriatrician adviser noted that there were indicators of poor oral intake and dehydration from 26 May and that this should have prompted a documented review of the fluid restriction and diuretic medication. This does not mean the plan would necessarily have changed, but the dehydration and the decision to continue restricting fluids and administering diuretics should have been documented, in line with the GMC’s Good Medical Practice guidelines. This did not happen.
41. From 2 June, due to dehydration, the doctors prescribed a 1 litre infusion of fluids to be delivered intravenously (directly into the vein). The doctors consistently documented that the nurses should encourage Mr A to drink oral fluids. The 1.5 litre fluid restriction was still in place.
42. The nursing team did not record any intravenous fluid infusion in Mr A’s records on 2 June. Intravenous fluids only commenced after a junior doctor noticed Mr A still looked dehydrated at 12.45am on 3 June, sought advice from a medical registrar, and commenced an infusion at 2.20am.
43. The documented fluid intakes for 3,4 and 5 June reflected an adequate intake, with the intake on 3 June being slightly over the fluid restriction (1,606mls).
44. On 6 June, a doctor documented that Mr A’s fluid restriction should be lifted as he continued to present as dehydrated. The doctor also documented that he had told Mr A to drink plenty of water and reiterated that this intake needed monitoring on the fluid balance charts.
45. The nurses’ documentation of his fluid intake from this point was inconsistent. On some days the nurses recorded an adequate fluid intake, and on others it was far below what was recommended. The nurses should have been aiming for at least 1.5 litres of fluid intake, as documented by the doctors, but this did not happen on a significant number of the days he was in hospital.
46. It is concerning that such inadequate fluid intake was documented on so many of the days Mr A was in hospital, especially as the doctors were documenting the need to ensure his oral intake was monitored and maintained.
47. We asked our geriatrician adviser whether the failure to adequately maintain and monitor Mr A’s fluid intake and output could have caused his condition to deteriorate and/or whether it contributed to his death. Our adviser explained there were, sadly, multiple reasons why Mr A deteriorated, and this was more likely than not a result of his complex medical needs than solely due to dehydration.
48. Our geriatrician adviser also explained that national guidelines for managing heart failure (NICE guideline NG106) and national guidelines on managing impaired kidney function (NICE guideline NG148) create a complex clinical picture with contradictory management approaches. In short, the treatment for heart failure can cause dehydration and adversely affect kidney function, but the heart failure itself can also have serious consequences for kidney function if not treated. Research also shows that patients with congestive heart failure and impaired kidney function, sadly, have an elevated risk of mortality due to this complexity.
49. Because of the complexity of navigating Mr A’s competing clinical needs, dehydration was a likely clinical outcome even if his fluid balance had been diligently and robustly documented and maintained.
50. Our geriatrician adviser also explained that, with hindsight, Mr A’s reducing oral fluid intake was more likely than not an early indicator that he was approaching the end of his life. Sadly, patients who are entering the final weeks of their life experience significantly reduced thirst and desire to drink. Had the clinical team been documenting and monitoring his oral fluid intake more accurately, this could have given the clinical team the opportunity to discuss options for end-of-life care with his family sooner.
51. We cannot conclude the failure to appropriately monitor, maintain, and document Mr A’s fluid intake led to a less favourable clinical outcome for him. That said, our geriatrician adviser commented that this omission ‘would not have helped’ him, and knowing his care fell below national standards will cause his family distress. The family also lost the opportunity to have discussions about end-of-life care sooner, which has caused them further distress. The Trust has not acknowledged these failings, nor taken action to put things right. We have outlined recommendations to address these failings and their impact at the end of this report.
Hygiene 52. In line with NICE guideline CG138, the nurses should have ensured Mr A’s personal care needs were regularly reviewed and addressed. The nurses should have regularly asked him if he needed help, and his needs should have been addressed at the time of asking. The nurses should also have ensured this was done in a way that maintained his privacy and dignity.
53. Mr A’s care plan, dated 22 May 2022, states that he required ‘full assistance’ with washing, dressing, and oral care. A nursing note on 22 May reflects he was able to independently use the personal hygiene products to clean himself, and a lot of the support required appears to have been in the context of his mobility. The care plan states his support needs should be evaluated daily, and he was continent but needed help when mobilising to and from the toilet.
54. Mr A’s medical records reflect that support was being provided for personal hygiene and toileting. However, there were no comfort round records kept. Because of this, we have relied on the notes made by the nurses and whether they reflect personal care was provided. As per the care plan, his personal care needs should have been addressed daily.
55. Mr A’s medical records documented assistance being provided with washing and dressing on most days between 27 May and 21 June. There were some omissions in this documentation, and there is little documented about his toileting needs being met.
56. Although there was little documented about the support provided with toileting, in the context of a busy ward environment and Mr A being continent, we would not necessarily expect the nursing staff to document each time he went to the bathroom or used a urine bottle.
57. What the family seems most concerned about is a lack of basic hygiene support around toileting, and we can understand why this was concerning for them. They have shared an account from 2 June when the family say Mr A repeatedly asked to use the bathroom. They say that when the staff took him to the toilet, they left him in the toilet alone and nobody checked on him or came to help him back to his bed. Mrs A says she had to find a member of staff to come and assist him. She said she then noticed he had faeces up his arm and asked a nurse for assistance. Mrs A says the nurse provided two dry wipes to clean it up, and she had to use her own antibacterial wipes to clean the faeces from his arm.
58. We were very sorry to learn about this account and we understand why this was so distressing for his family.
59. The evidence shows Mr A was capable of using the toilet independently but needed support with mobility. His nursing assessments do not indicate he needed support with cleaning himself afterwards, though he did require access to the means of doing so. His medical records show he consistently mobilised to the toilet independently with no concerns documented.
60. When Mr A was in the bathroom on 2 June, he would have had access to hand washing facilities and was capable of using these independently. We note that on 2 June he experienced new-onset confusion at some point between 8am and 7.45pm, which may have impacted his ability to use these facilities independently. There is no contemporaneously documented evidence as to how this confusion may have affected his ability to maintain his hygiene. Even after enhanced observations were commenced on 4 June, the documentation does not reflect any difficulty in maintaining his own personal hygiene. We cannot know whether this was due to poor documentation or because he maintained his independence.
61. We have not found the care provided to Mr A fell so far short of NICE guideline CG138 that it amounts to service failure. That said, we recognise how distressing the incident on 2 June was for his family, and this decision in no way detracts from their experience. The Trust apologised for their experience during the local resolution meeting on 12 April 2023.Aspiration 62. Nurses should deliver the fundamentals of care effectively, as per the NMC Code, and this would include not giving a patient who was nil by mouth oral fluids.
63. There is no evidence that Mr A was given oral fluids whilst he was nil by mouth. We note that in his medical records there was 83mls of oral intake documented on 15 and 20 June. Our nurse adviser explained that this was most likely IV fluids that had been entered into the wrong place on the chart. This is evidenced by the fact that 1000mls of IV fluids over 12 hours equals 83mls per hour, and the fact that for each hour other than the instance of oral intake recorded, 83mls was consistently added to the section of his chart for recording IV fluids.
64. Aside from these two errors, there is no further evidence that could indicate Mr A was given oral fluids when he should have been nil by mouth.
65. What is also of note is that Mr A was documented as having symptoms of pneumonia on 9 June. He was not made nil by mouth until 14 June. Therefore, even if his pneumonia had been due to aspiration, this happened before he was made nil by mouth.
66. In summary, we have seen no evidence Mr A was given oral fluids after he was made nil by mouth on 14 June. Furthermore, he developed hospital-acquired pneumonia before doctors made this recommendation, meaning aspirating whilst nil-by-mouth cannot have led to his pneumonia.
Communication 67. With regards to the doctors’ communication with Mr A’s family, the GMC’s Good Medical Practice guidelines (section 33) state that doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. The guidance does not state when and how often families should be updated.
68. Our physician adviser explained that, in practice, doctors should offer to update a patient’s relative if asked to do so or if there has been a significant change in the patient’s condition. This would include when Mr A developed pneumonia, which is the main aspect of communication the family are concerned about.
69. On 9 June the doctors documented they suspected Mr A may have pneumonia and prescribed antibiotics to treat this. A chest X-ray showed new consolidation (where the air in the lungs is replaced with fluid or another substance) and blood tests showed increasing inflammatory markers, which confirmed the diagnosis.
70. The doctors documented that Mr A’s daughter was updated about this on 13 June, and that his wife was updated on 14 and 16 June. The GMC guidance does not say when Mr A’s family should have been told about this, and our physician adviser said this was an adequate timeframe within which to update the family. We have found the doctors’ communication was in line with the GMC’s guidance on communicating with families.
71. With regards to the nurses’ communication, in line with NICE guideline CG138 the nurses should have checked with Mr A whether and how he would like family to be involved in key decisions about his care. This should have been reviewed regularly and, with Mr A’s consent, the nurses should have shared information with his family as required.
72. We have reviewed the documented communication from the nursing team to the family and this fell far short of NICE guideline CG138. This is because we have seen no documentation around whether the nurses checked his preferences, and there were just three documented instances of the nurses updating the family over a period of a month. This falls so far below the communication expected by NICE guideline CG138 that it amounts to service failure.
73. We can understand that not having regular updates on Mr A’s care during the final months of his life would have been distressing for his family. We also acknowledge this likely caused his family unnecessary worry and frustration at an already distressing time.
74. The Trust acknowledged the communication fell short during its local resolution meeting with the family. It also put some actions in place to improve communication. Unfortunately, due to the poor standard of complaint handling, which we outline in more detail below, the audio of the meeting is unclear whether an apology was provided for this failing. A written summary, dated 20 August 2024, reflects the apology was in relation to communication during a meeting between the family and a doctor on 20 June 2022.
75. We are not satisfied the Trust has taken appropriate steps to put right the impact of its poor communication. We have outlined recommendations at the end of this report.Complaint handling 76. As Mrs A made a written complaint to the Trust on 28 September, it was required to handle this complaint in line with the NHS Complaint Regulations 2009. These regulations state that NHS service providers must:
• keep the complainant updated on the progress of the investigation • investigate the complaint ‘speedily and efficiently’ • if a complaint response is not sent within six months, write to the complainant and explain why • as soon as possible after completing the investigation, send the complainant a written response that includes a report explaining how the complaint has been considered and the conclusions reached.
77. The Trust wrote to Mrs A on 29 September. This letter outlined the issues it would be considering and that an investigation would take place. The letter explained a response would be sent to the family within 40 working days (by 23 November).
78. There is no evidence the Trust contacted Mrs A about the progress of the investigation during this period. An internal email indicates she contacted the Trust for an update on 22 November and asked for a meeting to discuss the complaint. The member of staff alerted the complaints team to this contact; however, there is no evidence of any update or contact being made with Mrs A until 8 March 2023.
79. We have found the Trust failed to initiate any updates to Mr A’s family between 29 September 2022 and 8 March 2023. It failed to meet its own deadline, and did not update the family after this. It also failed to send an explanation in writing when it had not provided a response within the statutory six-month period. This fell so far short of the NHS Complaint Regulations that it amounts to service failure.
80. Although the Trust did not meet its deadline of 40 working days, this does not in and of itself demonstrate an unreasonable delay. There can be good reasons for complaints taking longer, such as complexity or staff absence, for example. We have, therefore, considered whether the time taken to respond to the complaint was reasonable.
81. We have reviewed the work undertaken by the Trust in the complaint file it provided to us. The investigation appears to have commenced in a timely manner on 29 September 2022. However, the investigation document sent to us was never completed. Each section of the report states ‘please complete’.
82. There is some evidence of work being undertaken to investigate the complaint in internal emails, though this is sparse. On 3 October the investigation document was cascaded to the doctor and nurse who later attended the local resolution meeting, and a document was returned to the complaints team on 17 October. We do not know what this document was, however, as it has not been included in the evidence sent to us. Later emails indicate this may have contained additional concerns raised by Mrs A.
83. Another email from 17 October indicates the nurse had been unable to review and submit any responses to the investigation, and a matron could not find any notes relating to it. The nurse then sent a document that contained their response on 21 October. The Trust has not provided a copy of this document.
84. There is no further evidence of any action being taken regarding the investigation until Mrs A contacted the Trust on 22 November. A member of staff prompted the complaints team about this and noted Mrs A had raised additional concerns in October. There is no evidence of any action being taken until 9 January 2023, when a member of the complaints team was looking to arrange a local resolution meeting. There is no evidence of any further investigation taking place between January and the meeting in April.
85. We have found the Trust undertook very little action to investigate Mrs A’s concerns and issue a response between 29 September 2022 and 12 April 2023. This fell far short of the NHS Complaint Regulations’ requirement to investigate complaints ‘speedily and efficiently’ and amounts to service failure.
86. Following the local resolution meeting, the Trust sent Mrs A the recording of the meeting. However, at no point did it send any written response to her complaint. This fell far short of the NHS Complaint Regulations. It did eventually send a written summary of the meeting on 20 August 2024; however, this was only after we contacted the Trust and instructed it to do so.
87. In addition, both the recorded local resolution meeting and the written summary failed to explain how it investigated and considered the issues raised. It also failed to provide coherent conclusions on the outcome of the investigation. Although the Trust appears to have attempted to be proactive where it felt the service had fallen short, the value this had was diminished by the inadequate complaint handling prior to the action plan.
88. The Trust’s failure to issue a written response that outlined how the complaint had been investigated and the conclusions reached fell so far short of the NHS Complaint Regulations that it amounts to service failure.
89. Overall, the Trust’s complaint handling fell far short of the NHS Complaint Regulations in a number of areas, and we have found this amounts to service failure.