Attempts to administer morphine
10. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
11. Section 3 of the NMC Code says nurses need to ‘make sure that people’s physical, social and psychological needs are assessed and responded to’. Point 16c of GMC Good Medical Practice says doctors must ‘take all possible steps to alleviate pain and distress whether or not a cure may be possible’.
12. The Trust’s clinical notes say Mrs V was experiencing some radiating back pain following her TAVI procedure so the plan was to discuss with a doctor if paracetamol did not seem to relive this. The medication chart refers to paracetamol being administered but nothing to suggest the Trust gave her morphine.
13. The observation chart and the intentional rounding form show Mrs V’s pain score was 0 so there is no indication she needed strong pain relief, such as morphine. The only pain relief on the medication list in the Trust’s correspondence is paracetamol.
14. The Trust appears to have been acting in line with the relevant GMC and NMC guidance, as set out above. We have not identified any indication of a failing here.
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of the other events Mr V complained to us about.
Lack of own belongings in Mrs V’s room
16. Section 1 of the NMC Code says nurses have to treat people as individuals and uphold their dignity. Point 47 of GMC Good Medical Practice says this too. The Trust has said it should have taken action sooner to return Mrs V’s belongings. This indicates something went wrong.
17. Mrs V’s family feel it would have been important for her to access her property. They described some of the items Mrs V had with her and how she usually used them at home.
18. The Trust’s response acknowledged that after storing her belongings prior to her procedure, Mrs V’s belongings were returned to the family following her cardiac arrest. It said they should have been retrieved immediately after the procedure and it would feed that back to the nursing team.
Family seeing Mrs V deceased without warning
19. Section 5.5 of the NMC Code says ‘share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’. The Trust could potentially have done more to ensure it was acting in line with the NMC Code and it has recognised this.
20. The Trust’s records say Mrs V died at 9.39am. We understand her husband and daughter came to the ward to visit her at around 11am. The Trust’s records say staff asked them to wait by the reception for an update and there was a ‘do not disturb’ sign on Mrs V’s door. We appreciate the family’s recollection differs to the Trust’s account.
21. The Trust confirmed the family was not informed of Mrs V’s passing before the family arrived at her room. It has clearly been difficult for the family to come to terms with her unexpected death, making a challenging experience even more difficult.
22. The Trust’s complaint response explained there had been a miscommunication between staff and the family’s arrival soon after the arrest call ended added to this. It said there had been a learning debrief where it discussed the events with the staff involved. It offered apologies for the family’s experience.
Description of Mrs V as a ‘frail old lady’
23. Point 33 of GMC Good Medical Practice says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. The Trust’s communication in relation to this issue may not have reflected this. It must have been very hard for the family to hear the Trust use these words shortly after their bereavement.
24. The Trust has acknowledged Mrs V was not clinically frail and it should not have used that term following her death. This is an indication of a failing. The Trust said it apologised for this during the local resolution meeting.
Conclusion
25. We know we cannot change Mrs V’s experience or the way in which her family have been affected. When we see signs something has gone wrong, we look at the action the organisation has taken in response to the complaint.
26. Our Principles for Remedy say in many cases, an apology and explanation may be a sufficient and appropriate response. We can see the Trust provided appropriate apologies during the complaints process and acknowledged things it could have done differently.
27. Mr V would like the Trust to improve its service to prevent other families having a similar experience. We can see the Trust has already provided some clarification and taken action to learn from the family’s experience. We cannot see that there is more for us to do in relation this and we hope this gives the family some confidence in the Trust’s investigation.
28. We would like to take this opportunity to thank Mr V for taking the time to bring his complaint to us and reiterate our condolences for his family’s loss.