The Trust’s decision to discharge Mrs O on 3 June 2021
21. Mr O says his wife was not medically stable for discharge on 3 June 2021. He says she was vomiting on collection and continued to vomit violently whilst at home. He says the fall at home on 5 June only occurred because Mrs O was in a weakened physical state. He feels it would not have happened had the Trust kept her in hospital to fully recover.
22. We recognise it must have been very upsetting for Mr O to witness his wife unwell. It would have also felt worrying she needed another hospital admission so soon after being discharged.
23. ‘Good Medical Practice’ says a doctor must provide a ‘good standard of practice and care’. It says a doctor must ‘adequately assess the patient’s conditions’, ‘take into account their history’, and ‘promptly provide suitable advice, investigations, or treatment’ where necessary. A doctor must also ‘refer a patient to another practitioner’ when this serves the patient’s needs.
24. We asked our geriatrician adviser to tell us whether Trust staff ‘adequately assessed’ Mrs O’s condition and made sure she was medically optimised for discharge on 3 June in line with GMC guidelines.
25. Our geriatrician adviser confirmed the records indicate Trust staff correctly considered Mrs O’s clinical history. This included the impact of her fall with a long lie on floor, PD, and initial positive COVID-19 test result. Further, the Trust undertook appropriate and prompt investigations to assess her symptoms prior to discharge. This included x-rays, blood tests, and CT scans. Oue geriatrician adviser confirmed the records show Trust staff then put in place a suitable treatment plan based on these test results during Mrs O’s admission to make sure she was stable and fit for discharge. These actions are in keeping with GMC guidelines.
26. The records show the reason for Mrs O’s fall was because her PD symptoms had deteriorated. In line with GMC guidelines, the Trust referred Mrs O to an appropriate practitioner (PD services) for a review on 25 May. The PD specialist also recommended the Trust’s medical therapy team review Mrs O to help with her mobility.
27. On 24 May, Mrs O tested negative for COVID-19. She was also not displaying symptoms of COVID-19. On this basis, Trust staff felt the result had been a ‘false positive’ and there was no reason to keep her as an inpatient in an isolation cubicle.
28. On 26 May, the Trust considered Mrs O medically optimised for discharge. It put PD follow up care in place and referred her to the medical therapy team regarding ongoing therapy to maintain her mobility.
29. NHS England (NHSE) ‘implementation of a discharge to assess (D2A) model’ (2016) is the framework used by NHS staff to help them safely discharges patients. This guidance is included in the DHSC ‘Hospital discharge and community support’ guidance (2020).
30. The D2A model involves providing short-term care, rehabilitation and reablement, where needed, and then assessing people’s longer-term needs for care and support once they have reached a point of optimal recovery. This may be in people’s homes or using ‘step-down’ beds to support the transition from hospital to home. This means people do not wait unnecessarily in hospital, where there is a higher risk of acquiring infections or a decline in physical function of the body because of physical inactivity and bedrest (deconditioning).
31. DHSC ‘hospital discharge and community support’ guidance (2020) sets out the pathways Trust staff should consider prior to discharging a patient.
32. It states where a patient is likely to need an interim package of care on leaving hospital, pending any assessment of their longer-term care needs, the relevant care transfer hub should make sure a multidisciplinary team (MDT) assesses the appropriate discharge pathway (type of setting) and any immediate support the person will need on discharge. This includes confirming any immediate home-based support required to make their home suitable for discharge and/or social care packages of support.
33. Pathway one is for a discharge home with health and/or social care support co-ordinated by the care transfer hub. This includes home-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery at home.
34. DHSC guidance also says hospital wards and discharge teams should identify from the outset when a person wishes to be involved in discussions and decisions about their discharge. They should make sure patients and carers are involved at the earliest opportunity in discharge planning, for adult patients who are likely to need care and support following discharge.
35. The Trust’s medical therapy team did an initial assessment on 27 May. It gave ongoing input until Mrs O’s planned discharge date. The records show the medical team discussed Mrs O’s progress. Unfortunately, due to her shoulder pain, she was unable to use a walking zimmer frame. The Trust suggested a rehabilitation unit to help her with her mobility. Mr O was reluctant to do this because Mrs O had an appointment on 16 June regarding her shoulder pain.
36. On 28 May, the medical therapy team documented Mrs O’s mobility was improving, but she still required the assistance of one person when mobilising. The team recommended Mrs O undergo an MDT assessment to determine if she could be discharged home with a package of care.
37. The Trust had an MDT meeting on 31 May. It decided Mrs O was medically stable for discharge and could be discharged home under pathway one.
38. Mr O asked for an update regarding Mrs O’s medical condition and for the Trust to produce a negative COVID-19 result before he would accept her discharge home. This was because he wanted to make sure he could safely support his wife. The Trust did a further COVID-19 test, which produced a negative result. Mr O agreed to pick Mrs O up to take her home on 3 June.
39. Our geriatrician adviser explained prior to Mrs O’s discharge, the medical therapy team documented she was ‘interacting well with therapy’. The medical review shows she continued to be medically stable, was COVID-19 negative, and her observations were documented as normal.
40. There were no reports of nausea or vomiting in the days leading up to, and the day of her discharge home. The Trust considered Mrs O had capacity to be involved in decision making around her discharge. The records show Trust discussed her discharge with her. She was keen to go home with agreement from Mr O. This evidence indicates Trust staff did appropriately ‘assess, identify, and plan’ for Mrs O’s safe discharge home with the involvement of Mr O. This was in line with GMC, NHSE, and DHSC guidance. On this basis, we have seen no evidence of failings in the decision to discharge Mrs O on 3 June.
Medication decisions:
41. Mr O says Trust staff made changes to Mrs O’s prescribed medication. This included gabapentin (medication used to treat nerve pain), fluoxetine (anti-depressant medication), and sinemet (a brand name of co-careldopa medication used to treat PD).
42. He says this led to her continuous sickness and weakened physical state. He says he tried to inform Trust staff the abrupt changes would have serious side effects for his wife. He feels these concerns were dismissed and not listened to.
43. Mr O had previously successfully managed Mrs O’s conditions at home. It is clear Mrs O’s admission to hospital caused him distress. We understand how important it was for him to know his wife was receiving the best possible care and treatment whilst she was in hospital.
44. The Trust says, during Mrs O’s second admission, it appropriately changed her medication based on her presenting issues.
45. The records indicate Mr O raised concerns about changes to his wife’s medications on 7 June. He said any changes would have to be done in a ‘monitored fashion’. He said a reduction in Mrs O’s gabapentin would cause her ‘pain to flare up’ and would put her ‘in agony’ and she will ‘cry hysterically’.
46. NICE ‘Neuropathic pain in adults: pharmacological management in non-specialist settings’ (2020) explains how to prescribe gabapentin. It says clinicians should ‘taper the dose’ but use an ‘individualised approach’, so there is no set regimen to follow. Section 1.1.7 says, when withdrawing or switching treatment, ‘taper the withdrawal regimen to take account of dosage and any discontinuation symptoms’.
47. The records show Trust staff reduced Mrs O’s gabapentin on 7 June from 400mg three times daily to 200mg three times daily. This medication was then stopped 8 June and replaced with oromorph. Our geriatrician adviser explained Mrs O was frail, experiencing falls, and was taking many medications which can cause side-effects (“polypharmacy”). Gabapentin has the potential to exacerbate Mrs O’s conditions and its clinical benefit to her was uncertain. Therefore, the Trust’s rationale for reducing and stopping gabapentin was clinically sound and fully explained in the clinical records.
48. NHSE ‘How and when to take gabapentin’ (2018) says it is important not to suddenly stop taking gabapentin as it can cause serious problems. Stopping gabapentin suddenly may lead to a severe withdrawal syndrome. This can have unpleasant symptoms, including anxiety, difficulty sleeping, feeling sick, pain, and sweating. It is possible to prevent withdrawal seizures and other symptoms by gradually reducing the dose of gabapentin.
49. Our geriatrician adviser said although Mrs O was on a low dose of gabapentin (1200mg daily), the dose reduction was abrupt over a two-day period. It would be reasonable to discontinue a dose of 1200mg daily over a period of days to short weeks to avoid withdrawal symptoms. The Trust’s quick reduction in Mrs O’s gabapentin medication was not in line with NICE or NHSE guidance.
50. At times between 14 and 17 June, Mrs O became ‘very agitated’, ‘upset’, and physically abusive towards nursing staff. During this period, Trust staff asked Mr O to come to the hospital to help calm her down.
51. We recognise these symptoms could be caused by the introduction of new medication. However, on balance, we consider it is most likely because of the quick withdrawal she experienced from gabapentin as outlined in NHSE guidelines. This explains patients can experience anxiety, sickness, pain and sleeping difficulties if medication is withdrawn too quickly. These were Mrs O’s symptoms shortly after stopping this medication
52. NICE ‘Depression: switching antidepressants’ guide (2019) says to be aware interactions with fluoxetine may still occur for five weeks after stopping it. It also recommends to cross-taper cautiously when switching from fluoxetine to another antidepressant.
53. On admission, Mrs O was taking 40mg of Fluoxetine once a day. The records indicate the Trust stopped this medication on 7 June and mirtazapine (an alternative anti-depressant medication) at 30mg once daily was started.
54. Our geriatrician adviser says the rationale for change from fluoxetine to mirtazapine is not fully explained in the records. The clinical notes indicate this was to help Mrs O’s anxiety symptoms. That said, the changes the Trust made to her prescribed gabapentin and fluoxetine medication were not in keeping with NICE recommendations. It should have gradually reduced the fluoxetine while simultaneously starting the mirtazapine at a low dose and gradually increase it.
55. Mr O says he did not know Trust staff had administered mirtazapine to Mrs O during her admissions until he received the Trust’s response. He says this medication had previously had a negative effect on Mrs O. Her symptoms included confusion, nightmares, vagueness, sickness, swollen legs, aggression, and she became unsteady on her feet. Mr O says, if Trust staff had listened to his concerns about the changes to Mrs O’s medication and told him it was proposing to administer mirtazapine, he could have told them of her previous issues with the medication. He says Mrs O suffered unnecessarily because Trust staff gave her mirtazapine.
56. There is a record of allergies or type of reactions in Mrs O’s records. There was no record of previous adverse reaction she had from previously taking mirtazapine. The reported symptoms from her psychiatry records were after taking two doses of mirtazapine stating she ‘seemed unwell the next morning and her legs and feet were swollen, she fell off the toilet and was trying to stand on the balls of her feet’.
57. Our adviser explained it was reasonable for the Trust to retrial mirtazapine, particularly as Mrs O was in a monitored environment. This is because causation and correlation cannot always be proven, especially where symptoms are non-specific as Mrs O’s symptoms appear to have been after previously taking mirtazapine. Therefore, we accept the Trust’s clinical decision on this.
58. Mrs O was first prescribed and received mirtazapine during her first admission on 22 May. This was discontinued straight away when it became apparent her GP had stopped her taking it and it had made her vomit. Mrs O’s fluoxetine was switched to mirtazapine on 7 June. The Trust stopped mirtazapine on 14 June following Mrs O’s delirium and possible correlation between the changes in her medication. The records indicate she was given doses of lorazepam on 14 and 15 June. There is no evidence to suggest any other anti-depressant medication was given after this time.
59. NICE ‘Patient experience in adult NHS services: improving the experience of care for people using adult NHS services’ (2021) says healthcare services should be tailored for each patient. This means clinicians should clarify with the patient at the first point of contact whether and how they would like their partner, family members and/or carers to be involved in key decisions about the management of their condition (or conditions). If the patient agrees, the guidance says clinicians should share information with their partner, family members and/or carers.
60. On 14 June, the documents state Mrs O became aggressive and physically abusive towards Trust staff. Mr O was requested on occasions to attend the hospital to try calm her down. It is clear Mrs O relied heavily on Mr O’s support, and she valued his opinion and involvement in her care.
61. The records indicate the Trust informed Mr O of its decision to change Mrs O’s medication from fluoxetine to mirtazapine. That said, on the balance of probabilities, we are of the view Mr O would have raised concerns at the time if he had been made aware of this specific change to Mrs O’s medication.
62. Mrs O developed a delirium on 14 June. The Trust acknowledged the possibility of it being due to the recent medication changes, whilst also investigating for additional possible causes.
63. By 23 June, the delirium improved, and Mrs O reached a medically stable condition. The Trust agreed to plan her discharge to a rehabilitation unit to improve her mobility. Therefore, it is unlikely there was a significant impact of the medication changes to her later clinical deterioration, cardiac arrest, and death.
64. NHSE ‘Parkinson’s disease treatment’ guide (2019) gives information around the medications that are used to improve the main symptoms of PD, such as shaking and movement problems. This includes the use of co-careldopa (Sinemet) and rotigotine skin patches.
65. Our geriatrician adviser said the records show Trust staff continued to give Mrs O sinemet. For periods where she could not reliably take the medication by mouth because of episodes of vomiting or she was nil by mouth, a rotigotine patch was used in place of the sinemet tablets.
66. This is recommended and standard practice as Parkinson’s treatment should not be omitted or abruptly stopped. There is a note by a PD specialist on 25 May which stresses the importance of ensuring Mrs O receives her medication on time. However, there is no evidence the Parkinson’s treatment (sinemet or rotigotine) was stopped during Mrs O’s admissions.
67. In summary, we are of the view the Trust’s handling of Mrs O’s medication was not in line with NICE and NHSE guidance and fell below the standards expected. We can see Trust staff stopped Mrs O’s Gabapentin abruptly within two days. This falls short of NICE guidance, which states medication should be reduced slowly. Mrs O went on to suffer symptoms of anxiety, confusion, aggression, feeling sick, and difficulty sleeping. According to the guidance, these are known symptoms which occur when Gabapentin is stopped abruptly. Therefore, on balance, we can attribute Mrs O’s poor side effects to stopping this medication.
68. Additionally, we can see Trust staff stopped her Fluoxetine medication and swapped it for mirtazapine, an alternative anti-depressant medication. NICE guidance and our geriatrician adviser, explains anti-depressant medication should be ‘cross tapered cautiously’. This did not happen in this case and shows the decision to change Mrs O’s antidepressant medication fell below the standard expected.
69. We consider Mr O will be left knowing his wife’s medication management could have been better during her admission. This will cause him frustration and distress. He will be left knowing she may not have suffered withdrawal symptoms or her withdrawal symptoms may not have been as severe had her medication been managed appropriately.
The Trust’s decision not to use a nebuliser
70. On 15 June, Mr O told Trust staff he wanted his wife to have an asthma inhaler and nebuliser at her bed. He says Trust staff showed him a report from its respiratory department from June 2020 which said Mrs O had mild obstructive sleep apnoea and did not require continuous positive airway pressure (CPAP).
71. Mr O says the Trust should not have relied on a year-old report. A CPAP is also different to a nebuliser and works in a different way. Mr O says Mrs O had a nebuliser attached to her bed on her admission to the Trust’s ICU.
72. NHSE ‘Treatment for COPD’ (2019) says nebulised medicine may be used in severe cases of COPD if inhalers have not worked.
73. During Mrs O’s second admission, the prescription charts show Trust staff were giving her a trimbow inhaler (a combination inhaler of three different medications for COPD). The prescription chart indicates she received this medication twice a day at 8am and 8pm apart from 8pm on 18 June and 8am on 19 June. The records do not say why Mrs O did not receive her inhaler on these two occasions. However, the records show she was confused, unsettled, and anxious, which is most likely the cause for her missing her medication on these dates.
74. Our geriatrician adviser agreed with the Trust’s reasons for not attaching a nebuliser to Mrs O’s bed. This is because Mrs O was given her inhaler as prescribed and there was nothing to suggest she experienced an exacerbation of breathing problems, such as a wheeze, to warrant an escalation in treatment to include the use of a nebuliser as per NHSE guidance. The clinical situation in ICU was very different. Mrs O was intubated and on a ventilator. Therefore, the treatment she required during her ICU admission has no significant bearing on the treatment she needed during the ward admission.
75. We appreciate Mr O’s reasons for requesting the use of a nebuliser. Given the number of changes that had been made to Mrs O’s medication, it is understandable that it caused Mr O distress not having the inhaler visible during his visits. We also understand this could have caused Mrs O distress too if she did not have it available to her. We consider the Trust’s decision not to provide a nebuliser was appropriate and in line with NHS guidance. We hope it gives Mr O reassurance to know Trust staff did give her this medication twice daily.
Failure to accurately record information and advice on how to best support Mrs O with her broken shoulder when giving her nursing care
76. On 21 June, Mr O says he heard Mrs O groan whilst being assisted by a member of Trust staff. Mr O says Mrs O told him the staff member had lifted her by her broken shoulder whilst trying to roll her over. Mr O says he reported it to a senior member of staff and asked why this information was not recorded on her bed board. Mr O says Trust staff told him they could not put it on the bed board for data protection reasons. Mr O says, on 23 June, Mrs O’s injured shoulder had been written up on the bed board.
77. The Trust has not given a view on the nursing care given to Mrs O in relation to her broken shoulder.
78. NMC ‘The Code: professional standards of practice and behaviour for nurses, midwives, and nursing associates’ (2018) says nurses must ‘identify any risks or problems that have arisen, and the steps taken to deal with them’. These records must be ‘clear and accurate’ to enable colleagues who use the records to have all information they need.
79. For Mrs O’s first admission, the ambulance staff handover report documents her left shoulder fracture. The Trust’s ED clerking records also report an aggravation of the left shoulder due to the fall. The assessment record completed in ED on 5 June, also has information relating to her shoulder injury and the number of cancelled operations she has had. Therefore, our nursing adviser says, this information would have been available for all Trust staff.
80. The records indicate nursing staff assessed Mrs O’s needs during her two admissions. This outlines what care she was being provided. However, there is no information included in the assessments, on how best to support Mrs O with her shoulder injury other than the medication she was being administered for pain relief.
81. From the nursing advice obtained it is our view this falls below the NMC standards. It is not clearly documented what specific steps Trust staff needed to consider when providing nursing care to Mrs O during her hospital admissions. We consider nursing staff should have ‘clearly and accurately’ recorded information on Mrs O’s shoulder injury and the steps needed to safely assist her during her hospital admission.
82. The poor documentation around the support Mrs O needed means we do not know whether nursing staff took appropriate steps to prevent her experiencing pain when giving her nursing care. The nursing records show there were times when Mrs O became ‘agitated and upset’ and she also became physically aggressive when Trust staff tried to give her personal care. On balance, we conclude she must have experienced some pain and discomfort at times when nursing care was being given. For that reason, we uphold this part of the complaint.
The Trust’s decision not to give Mrs O an echocardiogram during her second admission
83. Mr O says Mrs O had an echocardiogram appointment scheduled for 16 June at a different Trust. Mr O says this appointment was important as it was needed before any surgery for her shoulder could be arranged.
84. The records show Mr O raised this with Trust staff and asked if the echocardiogram could be done whilst she was an inpatient. This was to prevent any further delays in her receiving the necessary treatment for her shoulder. At this request, Mr O says Trust staff asked him whether he thought it was a ‘one-stop shop’.
85. The records state Mrs O was not fit to attend the outpatient test at a separate Trust. The Trust said it would look at what it could do with regards to an inpatient appointment, but it was unlikely given its own long waiting lists.
86. GMC’s ‘Good Medical Practice’ says the investigations or treatment you provide or arrange must be based on the assessment you and your patient make of their needs and priorities, and on your clinical judgement about the likely effectiveness of the treatment options.
87. As the information from the echocardiogram was required by a separate hospital trust to plan for future surgery, the treating team at the other Trust would want to conduct its own tests. Further, as not all scans are compatible across different Trust’s, it may not have been able to view or use the information gathered.
88. The records show this was explained to Mr O. Whilst we are not disputing what Mr O has told us, there is nothing to suggest anything inappropriate was said to him. It is documented he agreed to call the other Trust to cancel the test and would let the Trust know when it is rebooked for.
89. This was clearly a distressing time for Mr O. We are sorry to hear he felt further disappointment when the Trust did not undertake this procedure. We fully understand Mr O’s reasons for requesting the test be conducted by the Trust because he did not wish for Mrs O to continue to suffer in pain. Sadly, this was not possible. Whilst this was disappointing, we accept the reasons given by the Trust. Therefore, we will not be taking any further action on this part of the complaint.
The Trust’s decision to begin planning Mrs O’s discharge to a rehabilitation unit on 23 June 2021
90. Mr O says he cannot understand how the Trust could consider Mrs O ‘medically stable’ for discharge to a rehabilitation unit on 23 June and then for her to be ‘fighting for her life’ by the early hours of 27 June.
91. Annex 4 of the Department of Health & Social Care ‘Hospital discharge and community support’ guidance (2020) sets out the ‘criteria to reside’ for inpatients. –If a patient does not meet the criteria, then active consideration for discharge to a less acute setting must be made.
92. Further, RCP ‘National Early Warning Score (NEWS) 2’ (2017) explains the NEWS2 scoring system is used to monitor patient vital signs and identify those who may be deteriorating. A set of vital signs, including heart rate, blood pressure, respiratory rate, oxygen levels, and conscious levels are recorded and scored.
93. The records indicate Mrs O was medically optimised for discharge during the daily consultant clinical review on 23 June at 09.40am. The document correctly includes a NEWS2 score. Trust staff took Mrs O’s observations, which included blood pressure, heart rate, respiratory rate, temperature, and oxygen saturations.
94. Our geriatrician adviser says these observations were all within normal range. She was clinically examined, and the chest x-ray performed the previous day was also reviewed. Her NEWS score was zero, and she was not on intravenous therapy or oxygen. Therefore, the clinical decision to plan Mrs O’s discharge to a rehabilitation unit was in line with GMC, DHSC, and RCP guidance.
95. Sadly, Mrs O’s medical condition did not remain stable for long. The records show at 7.30pm on 24 June that she started to bring up small amounts of ‘coffee ground’ vomit. The doctor continued to monitor, investigate, and review her situation. The abdominal x-ray showed there was no obstruction, and the doctor agreed to continue with laxatives. The plan was to give Mrs O anti-emetics and to stick with the rotigotine patch rather than oral co-careldopa to avoid her rejecting it. The blood tests showed Mrs O was ‘very mildly dehydrated’ and she was put on intravenous fluids from 11pm on 24 June.
96. Health and Social Care Act 2008 ‘Code of practice on the prevention and control of infections and related guidance’ says good infection prevention control is essential to ensure people receive safe and effective care. For people who are identified as a risk should receive appropriate treatment and care to reduce the risk of transmission of infection to other people.
97. Mrs O continued to bring up ‘coffee ground’ vomit. On 25 June, a consultant reviewed Mrs O and diagnosed her with possible viral gastroenteritis. cause. The treatment plan included a request for a ‘cubicle’ or side room. Our geriatrician adviser says this was appropriate and in line with the HSCA to try to reduce the risk of transmission to other patients because of the possible infectious cause.
98. We recognise how upsetting and distressing it was for Mr O to witness his wife significantly deteriorate so quickly after being told she was fit for discharge on 23 June.
99. From the clinical advice sought and reviewing the records taken at the time, we consider the Trust did appropriately assess Mrs O and made a sound clinical decision to plan for her discharge to a rehabilitation unit. Sadly, she began to deteriorate shortly afterwards. We are of the view the Trust acted accordingly by putting her in a side room to prevent the risk of spreading an infectious disease to other patients. Therefore, we do not uphold this part of the complaint.
Failure to conduct observations on time and nursing notes in a detailed manner
100. Mr O says the medical and nursing team did not adequately monitor Mrs O’s fluid intake or hydration levels. They also did not carry out frequent wellbeing checks to monitor her overall wellbeing. He says he supported Mrs O on 26 June with approximately six or seven bouts of sickness. He says there were no nursing visits undertaken in over six hours whilst he was present.
101. NMC ‘The Code: professional standards of practice and behaviour for nurses, midwives, and nursing associates’ (2018) says nurses must keep ‘clear and accurate records’ to identify any risks or problems that have arisen, and the steps taken to deal with them so that colleagues who use the records have all the information they need.
102. Our geriatrician adviser said the Trust recorded poor and inconsistent fluid balance charts. This can impact the ability to pick up early signs of dehydration and acute kidney injury (AKI).
103. On 24 June, the records indicate Mrs O was mildly dehydrated and she began intravenous fluids. This may only have become apparent when Mrs O became symptomatic. The documentation was hardly completed on occasion to give an accurate assessment of Mrs O’s oral intake and output. This falls short of an expected standard of monitoring of fluid balance.
104. RCP NEWS guidance says a NEWS score of zero should have a minimum 12-hour frequency of monitoring. Patients with NEWS scores 1-4 should be monitored every 4–6-hours.
105. From clinical advice obtained, the nursing records during this admission for Mrs O do not indicate any high NEWS scores or clinical concern that would warrant an increased frequency of reviews by the medical team. Therefore, the visits she had from the medical team were satisfactory.
106. On 26 June, the intentional rounding (the structured process whereby nurses in hospitals carry out regular checks to address issues of positioning, pain, personal needs, and placement of items) records indicate Mrs O was visited at 11.45am, 2pm, 2.10pm, 4.35pm, 8.35pm, and 10.55pm. This is in line with the above guidance. Further, Trust staff correctly did a NEWS2 assessment at 4.49am, 3.11pm, and 8.27pm. There is no record of nausea or vomiting in the NEWS chart on 26 June. We are not saying Mr O’s recollection of the events are incorrect and we do not wish to underestimate the level of distress he was under at the time. That said, on balance, it appears nursing checks were completed at the times stated in the records.
107. The NEWS observation chart shows Mrs O’s NEWS score was four at its highest on 23 June, gradually lowering to one on 26 June. In line with RCP NEWS guidance, the Trust appropriately put Mrs O on six-hourly monitoring.
108. On 26 June, we can see there was over 10 hours between the observations recorded between 4.49am and 3.11pm. This is not in line with NEWS guidance.
109. Mr O says Trust staff contacted him at home at 2am on 27 June to tell him Mrs O had been ‘discovered’ in a serious situation with choking, had a heart attack, and was in an unconscious state. The nursing records indicate the arrest call was put out at 2.49am. Therefore, he says there must have been a delay in Trust staff making the arrest call.
110. The arrest call log through the switchboard says the arrest call was made at 2.53am. Our geriatrician adviser says there can be slight differences between the times stated in the records and those on the call log. The reason for this is because the medical team will have likely used their watch to record the time whereas the call log time is registered through a switchboard. Therefore, 2.53am is the time the arrest call was registered. The records indicate Mr O was contacted at home around 3.30am. We cannot come to a firm view on when Trust staff contacted Mr O. That said, we do not have evidence from Mr O either to show he was contacted at 2am. Taking all information into account, we cannot reach a view on whether there was a delay in Trust staff making the arrest call.
111. There is nothing to indicate Trust staff should have foreseen a cardiac arrest. The hypoxic brain injury Mrs O suffered was due to a restriction in the blood flow to her brain which can happen during a cardiac arrest when the heart stops beating. The records state Mrs O was vomiting before and after the cardiac arrest but there was ‘no evidence of vomit on suctioning’. Following CPR, Mrs O’s heart began beating again. As she was unconscious, and unable to keep her airways clear, she was placed on a ventilator and taken to ICU. Sadly, Mrs O’s consciousness levels did not fully recover after the cardiac arrest.
112. The NEWS observation checks were due at 2.27am to be in keeping with the six-hourly checks. These were not recorded. The records are unclear as to whether a member of Trust staff was with Mrs O immediately prior to her cardiac arrest or whether a member of the nursing team attended her room as part of their routine checks. We cannot say on balance, whether the impact on Mrs O would have been less had staff been present prior to the cardiac arrest to help her to clear her airways. The injustice for Mr O is that he is left with unanswered questions, uncertainty, and further distress about the Trust’s care and treatment of his wife and whether her outcomes could have been better had these shortcomings not happened.
The Trust’s recording of Mrs O’s death
113. Mr O says Mrs O did not enter hospital with life threatening injuries. He says she died because of the conditions she acquired and the care she received at the Trust. He says the Trust has cited an inaccurate cause of death on Mrs O death certificate. He says her cause of death was a severe brain injury. He says the Trust should have referred her death to the coroner because it was ‘unnatural’ and as a result of ‘trauma’ that took place whilst she was at the Trust.
114. The Office for National Statistics (ONS) and HM Passport Office (HMPO) ‘Guidance for doctors completing Medical Certificates of Cause of Death (MCCD) in England and Wales’ (2010) says a doctor should start with the immediate, direct cause of death on line Ia, then to go back through the sequence of events or conditions that led to death on subsequent lines, until you reach the one that started the fatal sequence. Part II includes significant conditions that are not part of the direct sequence leading to cause of death but were ‘significant conditions’ that could have contributed to it.
115. Mrs O’s death certificate under I(a) shows the disease or condition leading to her death was Bronchopneumonia (a kind of pneumonia distinguished by inflammation and infection of the tiny airways surrounding lung tissue). Our geriatrician adviser says this was in line with the medical assessments and conclusions leading up to her death, so it was right to record this under this section.
116. Part II of the death certificate records other ‘significant conditions’ Mrs O had. These included Parkinson’s disease, Chronic obstructive pulmonary disease (COPD), and frailty. Our geriatrician adviser says, although these conditions were not the direct cause of her death, they could have contributed to it. It was therefore appropriate to record them in this section of the certificate, in line with ONS and HMPO guidance.
117. Considering all available evidence, we are of the view the Trust appropriately cited Mrs O’s cause of death in the death certificate in line with ONS and HMPO guidance. We understand Mr O wanted the Trust to refer his wife’s death to the coroner. However, as this is a legal function, we cannot comment on the Trust’s decision not to refer her death.
Complaint handling
118. Mr O says the Trust did not effectively handle his complaint and gave him contradictory responses. He says this has not helped him to understand the events that led to Mrs O’s deterioration and admittance to ICU. He says this has caused him further distress in an already upsetting and difficult situation.
119. On 4 July 2021, Mr O raised a complaint with the Trust about some of the care and treatment Mrs O had received. Mr O added to his complaint on 13 July. The Trust gave its initial response on 11 August 2021. Mr O remained dissatisfied with the response and replied to the Trust on 26 May 2022. The Trust gave its second and final response on 23 August 2022.
120. Our NHS ‘Complaints standards’ (2022) says organisations should ‘give fair and accountable responses’ with a ‘clear and balanced account of what happened based on established facts’.
121. In the Trust’s initial response, it says Mrs O reported feeling nauseous to a member of staff during the night of 27 June. It says the registered nurse on shift reviewed Mrs O and left her to prepare some anti-sickness medication. Whilst preparing to administer the medication, the nurse noticed Mrs O’s condition suddenly deteriorate and she became unresponsive. It was at this point the emergency buzzer was pulled, and a cardiac arrest call was made.
122. There is no documented evidence to suggest the version described in the Trust’s initial response is correct. This is not reflected in the clinical records and there is no witness statement logged to evidence this version of events. The information available is not clear and accurate to be able to say with confidence what happened.
123. The information given in the Trust’s second response gives a different view of this version of events. It states it had been unable to ascertain whether there was a staff member with Mrs O immediately preceding the cardiac arrest or whether the member of nursing team attended as part of their nursing checks.
124. We recognise it is not always possible to provide a detailed response for every aspect of a complaint. This can happen when there is not enough evidence or information to provide the level of response a person hopes for. That said, we consider the Trust has not acted in line with our complaints standards as it gave a response that was not ‘based on established facts’. We appreciate the upset and distress this has caused Mr O, and we realise it has affected his ability to find closure. We understand the pain and heartache Mr O has experienced by not knowing what happened leading up to Mrs O’s cardiac arrest or whether the care could have been better to prevent the events unfolding in the manner they did.
125. Our NHS ‘Complaints standards’ (2022) also expects organisations to ‘identify what learning can be taken from a complaint’ to ‘improve services and support staff’. The Trust’s complaints department has not highlighted any failings in its care and treatment of Mrs O between 21 May 2021 and 12 July 2021 (as outlined in this report). We consider the Trust needs to do more to put right the failings we have identified. We go on to explain this in the recommendations section below.