16. The relevant guidance which applies here is the Royal College of Physicians (RCP) National Early Warning Score (NEWS) guidance. The guidance outlines the recommended response according to the NEWS News Report (rcp.ac.uk). Under this guidance, a patient is assessed and given a score in relation to their physiological measurements. These can also be referred to as clinical observations and consist of;
• Respiration rate • Oxygen Saturation • Systolic blood pressure • Pulse rate • Level of consciousness or new confusion • Temperature
17. The above NEWS guidance indicates a total score of 5 or more should prompt the nurse to immediately inform the medical team and request urgent assessment by a clinician or team competent in the care of acutely ill patients. A medical review should then be completed within an hour. A score of 7 should also prompt the nurse to immediately inform the medical team and requested urgent review by the critical care outreach team, with consideration of transfer to level 2 or 3 care (high dependency unit or intensive care unit).
24 March 2020
18. On 24 March 2020 Mr Y had clinical observations taken during the period 6.51am to 8.45pm. At 10.24am Mr Y was scoring a 6, which had increased from 2 less than four hours earlier. This should have been escalated to the medical team in accordance with both the Trust’s policy and national guidance as his overall NEWS was above 5. We can see no evidence in the nursing records that this was escalated at this point, therefore this was not in line with guidance.
19. At 12.14pm Mr Y was scoring a NEWS of 7. This was escalated to both the medical team and the critical care outreach team, who both attended the unit to assess Mr Y. This was in line with guidance.
20. Our decision is there was a failing on the part of the nurse in failing to escalate Mr Y’s care at 10.24am in line with guidance when his NEWS was 6. We have considered the impact of this below.
27 and 28 March 2020
21. A surgical registrar carried out a review of Mr Y at 11.16am on 27 March due to his low oxygen levels (81%). The registrar requested a critical care outreach team and cardiology review. This was in line with guidance. However, there is no evidence a review took place.
22. Mr Y’s oxygen levels had increased to 95% by 11.23am. At 12.06pm the surgical registrar had a discussion with the microbiology team about Mr Y’s treatment. The recommendation was to take blood cultures. The microbiology team also advised against antibiotics but advised the surgical registrar to liaise with them if Mr Y’s temperature continued to spike or if he deteriorated.
23. When the nurse took Mr Y’s observations at 5.39pm he had a NEWS of 7. Our nursing adviser said that from the nursing care plan it is documented that this was escalated to the medical team, who reviewed Mr Y and indicated they were not concerned as they felt that he was stable.
24. However, our physician adviser said the action in response to the NEWS of 7 at 5.39pm was not in line with guidance. The nurse should not only have informed the medical team but should have requested urgent review by the critical care outreach team. The Trust should also have undertaken continuous observations and considered transfer to a high dependency unit.
25. Furthermore, whilst the nursing records indicate that the nurse did inform the medical team and they gave advice about what to do, he was not medically assessed in line with NEWS guidance. Our physician adviser said had the Trust undertaken the appropriate assessment, antibiotic therapy would have been restarted in line with the above NICE sepsis guidance and the advice given by the Trust microbiology team at 12.06pm.
26. Our decision is that there was a failing on 27 March to escalate Mr Y’s care at 5.39pm in line with guidance. This is acknowledged by the Trust’s medical examiner in her referral to the coroner. We have considered the impact of this failing below.
28 March 2020
27. At 3.46am on 28 March the nurse took Mr Y’s observations and recorded a NEWS of 7. The nurse should have immediately informed the medical team and requested urgent review by the critical care outreach team. Our physician adviser said that if Mr Y’s care had been escalated at 3.46am then he would have been reviewed by the medical team. He would have been started on antibiotics and placed on continuous monitoring. This may have resulted in the earlier detection of Mr Y’s low blood pressure and oxygen saturations. Our physician adviser said the combination of antibiotic treatment and continuous monitoring may have delayed Mr Y’s further deterioration at 7am.
28. At 7am the nurse was unable to get a blood pressure reading from Mr Y and she bleeped a doctor to come urgently. The doctor advised the nurse to try again and they would review the patient. The records show the nurse got a blood pressure reading at 7.15am but was unable to get an oxygen level reading. Mr Y then vomited and the indications are that despite attempts to suction him Mr Y sadly passed away.
29. The Trust‘s medical examiner said in her referral to the coroner that the nurse should have made an immediate medical emergency call to the MET (medical emergency team). This would have been in line with the Trust’s policy for deteriorating patients which indicates an unrecordable blood pressure is a medical emergency. Our decision is this was a failing and we have considered the impact of this below.
Impact
30. We have identified there are failings on the part of the Trust in escalating Mr Y’s care on 24, 27 and 28 March.
31. Ms X is uncertain as to whether escalation of her father’s care would have changed his outcome.
32. On 24 March 2020, following the observations at 12.14pm Mr Y’s clinical condition appeared to improve throughout the rest of the day. Regular clinical observations were taken and his NEWS score reduced to a 2 for the rest of the evening.
33. In the circumstances, whilst there was an occasion where Mr Y’s care was not escalated in line with NEWS guidance, his scores did subsequently improve. Our decision is that whilst there were failings on the part of the Trust there is no evidence this had an impact on Mr Y’s outcome. However, it will be a source of upset to Ms X that her father’s care was not managed in line with guidance.
34. When considering the failure to escalate Mr Y’s care on 27 March and at 3.46am on 28 March, our physician adviser said it was unlikely Mr Y would have survived even with appropriate escalation and treatment. This is because Mr Y had multiple problems following his operation on 5 March, the most serious being very severe heart failure. His heart muscle pump function, as assessed by the ejection fraction on echocardiogram, was only 20%. The normal range is 55-60%. This means that Mr Y’s heart was very weak and would not cope with any additional illnesses, even with appropriate treatment.
35. Ms X is also concerned that her father's care was not escalated to the MET as soon as the nurse identified her father had deteriorated at 7am on 28 March. She wonders if he had been seen sooner by the MET he may have survived or at least lived longer.
36. Our physician adviser said there is no evidence that any medical or nursing intervention in the immediate period prior to Mr Y’s death would have made any difference to his sad outcome. Our physician said the acute deterioration at 7am was extremely rapid. The nurse found a low BP then repeated it and it was normal but the oxygen saturations dropped very quickly and the patient died shortly afterwards. Our physician said the vomit happened at the time Mr Y died. He stopped breathing and vomited at the same time. Our physician said this was very likely part of the terminal event, as opposed to aspiration pneumonia.
37. Ms X also questions if her father died from Covid-19. The Trust’s medical examiner suggested in her referral to the coroner that Covid-19 was the likely cause of death. However, she said that she could not be sure he died from COVID-19. Furthermore, the original draft of the medical certificate of cause of death had included surgery in part 2, but this was removed. The Trust later told Ms X this was not correct, and that there should have been a discussion with the coroner at the time, given that the death was within 30 days of a surgical procedure. There is no post-mortem or coroner's inquest to confirm the exact cause of Mr Y’s death which has led to uncertainty for Ms X.
38. The advice from our physician adviser supports the Trust’s conclusions that Covid-19 was the likely cause of death based on the fact there was a COVID-19 outbreak on the ward at the time and that Mr Y was displaying clinical signs of infection. There is no evidence in the records to indicate another cause of death.
39. In the circumstances, our decision is that there were failings in the escalation of Mr Y care on 27 and 28 March. Taking into account the advice from our physician adviser, it is unlikely that Mr Y’s sad outcome could have been avoided. However, it will be a source of significant upset to Ms X that her father’s care was suboptimal.
40. Ms X says there was an missed opportunity for her to have been with her father during his final moments. If the nurse had escalated her father’s care at 3.46am then it is likely nursing staff would have called her to be with her father. The Trust has acknowledged that this was a missed opportunity. This too is a source of significant distress to Ms X who she does not feel she will ever get over missing the chance to say goodbye and to comfort her father in his final minutes, or the thought of him dying without a loved one present. This has affected her mental wellbeing. We do not underestimate how upsetting this must be for her.
41. The Trust has told us that since Mr Y's death, it has made several relevant improvements including: • the Critical Care Outreach Team (CCOT) now runs a 24/7 service, in addition, there is additional CCOT staff to provide standardised training on deteriorating patients for ward staff.
• introduction of the Medical Examiner role
42. We welcome the improvements made by the Trust. However, the Trust has not fully apologised for the above failings in care and recognised the impact on Ms X. Therefore, we have made recommendations below to provide a personal remedy to Ms X. We have also asked the Trust to provide Ms X with evidence to reassure her that the actions it planned after the complaint relating to the escalation of the care of deteriorating patients have been fully implemented.
Complaint handling
43. Our NHS Complaint Standards set out how NHS organisations should approach complaint handling. These include that an organisation is expected to give fair and accountable responses that set out what happened and whether mistakes were made.
44. Ms X complained to the Trust about her father’s care on 28 September 2020. This included concern about the failure to escalate his care on 28 March 2020. The Trust responded on 25 February 2021. The Trust said that the nurse followed guidance in contacting the doctor at 7am.
45. Ms X was unhappy with the complaint response and pursued her concerns with the Trust. This included meetings and information from the Trust’s medical examiner in their referral to the coroner. The Trust has acknowledged in its letter dated 27 March 2023 that it did not provide Ms X with the correct information in its earlier response about the escalation of her father’s care, which was not in line with the relevant standards. It apologised for the upset this had caused. However, the Trust did not acknowledge the failings to escalate her father’s care on 24 and 27 March which has added to Ms X’ upset.
46. Ms X has said that because she was initially misled by the Trust’s response and that she had to highlight concerns about the failure to escalate her father’s treatment she has no faith in the Trust’s conclusions. This has contributed to her distress and uncertainty during the complaint process. Ms X says this together with the poor care her father received have caused her mental wellbeing to be affected resulting in her requiring treatment from a psychotherapist.
47. The Trust has apologised to Ms X for the upset caused by the way it responded to her initial complaint, but we do not consider this fully provides a remedy to her. The Trust did not provide a written apology to Ms X for the other failings in her father’s care. We consider Ms X is entitled to a further personal remedy in line with our above ‘Principles for Remedy’. Therefore, we have made a recommendation below to address this.
Conclusion
48. We have identified failings in the care provided to Mr Y and the Trust’s complaint handling. We recognise that Ms X has been significantly affected by the loss of her father. We hope that our investigation and recommendations will provide some assurance to her what we have thoroughly considered this matter in reaching our decision.