Clinical care
26. Mrs O is concerned that an administrative error relating to Ms A’s date of birth on admission adversely impacted on the treatment provided to her. We have, therefore, considered why this administrative error happened and whether the care provided to Ms A was appropriate.
27. We have reviewed Ms A’s medical records, and this mistake appears to have been made by the ambulance service, not the Trust. This is because the handover document provided to the Trust by the ambulance service reflects the incorrect date of birth.
28. Due to Ms A’s confusion, she was unable give staff her correct date of birth. The ED clinician documented ‘patient cannot give [history] due to confusion, [history] taken from ambulance and ED notes’. This means the ED staff had to rely on the information provided by the ambulance service in the first instance. We recognise, however, why Mrs O is concerned about this impact this may have had on Ms A’s care.
29. We asked our Physician Adviser whether this oversight appears to have impacted on the care received by Ms A. Specifically, we asked whether the care provided was appropriate in the context of Ms A’s chronic kidney dysfunction.
30. Our Physician Adviser explained that not knowing Ms A only had one kidney would not have impacted on her care. This is because doctors use blood tests to establish how well the kidneys are functioning overall, rather than a verbal history. This type of test is called estimated glomerular filtration rate (eGFR). The eGFR tells doctors how efficiently a person’s kidneys are removing waste products and excess water from the blood.
31. Ms A had blood tests on admission and the doctors quickly identified she had impaired kidney function because her eGFR was low. The ED doctors also documented that they were aware of her reduced kidney function.
32. We also considered whether Ms A should have been given intravenous fluids and whether her treatment was appropriate in the context of her reduced kidney function.
33. The Trust has a policy for managing DKAs that is informed by and aligns with the guidance issued by the Joint British Diabetes Societies for Inpatient Care. This policy outlines the standard procedure for managing a DKA. The essential steps include:
• take venous or arterial blood gases (a blood test that helps doctors understand how well the body is handling breathing, metabolism, and circulation) • undertake tests to check for inflammation, infection, glucose, electrolytes, and waste products in the blood • prescribe fluids – usually one litre over 60 minutes via a cannula (a tube that is inserted into a vein) • prescribe and start fixed rate insulin (an infusion of insulin given at a fixed dose per hour) based on the patient’s weight. This can be estimated if the patient cannot be weighed.
• monitor blood glucose and ketones hourly • commence a strict fluid balance chart (a chart that monitors the fluid input and output for the patient).
34. It is not uncommon for doctors to have to balance the risk of harm in patients with competing and complex medical needs. Treating one medical need can commonly affect a different medical need, and doctors have to prioritise the most urgent need.
35. The evidence indicates the Trust followed its DKA protocol. As this was a life-threatening medical condition, the doctors had to prioritise resolving the DKA over any concerns about Ms A’s kidney function.
36. Our Physician Adviser explained that, on admission, Ms A was clinically dehydrated. This is common in a DKA as the glucose in the blood pulls water into the bladder and causes increased urination. A DKA can also cause vomiting, leading to further dehydration, and the ambulance crew reported Ms A vomiting prior to admission.
37. Due to how significantly dehydrated Ms A was on admission, she required intravenous fluids to save her life. This was one of the first steps on the DKA pathway, and our Physician Adviser explained this was a clinically appropriate course of action. We are satisfied the evidence indicates Ms A received clinically appropriate treatment from the Trust and that, had the Trust known her medical history, this would not have changed the treatment she received.
Communication
38. Mrs O was not informed of her sister’s admission to hospital and this meant she spent a day looking for her sister, contacting local hospitals and the police. This was, understandably, very distressing for her.
39. There is no national guidance which outlines when a patient’s next-of-kin should be informed of a patient’s admission to hospital. That said, the NMC Code says nurses should share information they need to know with carers and family members, so far as the law allows. Because Ms A was confused on admission to hospital, and could not contact her family herself, the nurses should have taken steps to do this.
40. The handover from the ambulance crew included the telephone number for Ms A’s friend. This meant the nursing team had a means of at least attempting to establish Ms A’s next-of-kin. The staff did not document any attempts to locate or make contact with Mrs O until the following day.
41. This appears to fall short of effectively communicating with Ms A’s family; however, we cannot know whether or not the nurses would have been able to make contact with Ms A’s friend using this number.
42. With regards to overall communication from the nursing team during Ms A’s admission, in line with the NMC Code the nurses should have updated her family when there were important developments in her care. This includes any changes to Ms A’s clinical condition and any transfers to different wards in the hospital.
43. The GMC’s Good Medical Practice guidelines also say that doctors should be considerate of those close to their patient and be sensitive and responsive in giving them information and support.
44. Doctors and nurses have different roles when communicating with patients/their family. Broadly speaking, doctors will update families on a patient’s diagnosis, prognosis and treatment. Nurses are responsible for day-to-day updates on a patient’s general condition and care, including when a patient is transferred elsewhere.
45. There is very little documented about the nurses’ communication with Ms A’s family prior to 9 October. We know a doctor updated Mrs O on 28 September, but there is nothing documented in the nursing notes to indicate the nurses considered what information needed to be communicated to Ms A’s family, nor that any information was provided. There is also little evidence of communication from the doctors regarding Ms A’s prognosis and treatment after the call on 28 September. This appears to fall short of the expected standard of communication.
46. On 8 October, Ms A was transferred to the Trust’s HDU. There is no evidence the nurses informed Mrs O of this transfer, which appears to fall short of the expected standard of communication.
47. After Ms A’s admission to the HDU, the communication appears to have improved, and Ms A’s family were updated regularly by both doctors and nurses between 9 and 29 October. Our Nursing Adviser also noted that when Ms A’s DKA had resolved she was no longer confused and was assessed to be able to communicate effectively. Her family were regularly visiting, and she was able to update them alongside the communications from the clinical team. This appears to align with the expected standard of communication.
48. Ms A was transferred to the Trust’s ICU on 22 October and there is a well-documented account of this being communicated to Mrs O. This indicates the communication aligns with the expected standard regarding this transfer.
49. Overall, the evidence indicates the Trust’s communication fell short early in Ms A’s admission. We understand this was distressing for Mrs O. The Trust has apologised for failing to update Mrs O about the transfer on 8 October and it has agreed to also apologise for the overall poor communication between 27 September and 9 October. We consider this is a fair and proportionate action to put things right, in line with our NHS Complaint Standards.
Death certificate
50. Prior to 2024, there were no guidelines or legislation that specified the time within which a death certificate should be completed. However, our Physician Adviser explained that in hospitals, it was always usual practice is to complete the death certificate as soon as possible, typically within three to five working days. The certificate is then verified by the hospital’s Medical Examiner.
51. There may be unusual circumstances which cause a delay. For example, if the treating clinicians are absent from work this can delay the death certificate because, by law, only doctors that have treated the patient can complete this.
52. In Ms A’s case, she had been in hospital for approximately one month and had received treatment from a number of different clinicians. This means there were likely multiple doctors who could complete her death certificate, and it is unlikely all these clinicians would have been unavailable to complete it within three to five days. The Hospital provided no explanation as to why this delay happened in its response to Mrs O.
53. We asked the Trust for more information about why the death certificate was delayed and what it has done to prevent delays in future. The Trust explained the hospital’s Medical Examiner initially disagreed with the information on the death certificate, which delayed it being completed. This happened over the weekend, meaning the issue could not be resolved until Monday.
54. Following Mrs O’s complaint, the Trust raised the issue of timeliness when completing death certificates at the Trust’s Mortality and Morbidity Surveillance Group meeting.
55. The Trust appears to have taken this issue seriously and provided further explanation regarding the reasons for the delay. We recognise this set of circumstances was distressing and less than ideal for Mrs O and her family. That said, the explanation appears to be an unusual set of circumstances that may have been unavoidable. For this reason, we cannot robustly conclude the delay in issuing the death certificate amounts to service failure. This in no way detracts from the distress caused to Mrs O and her family.
Complaint handling
56. Our NHS Complaint Standards say that organisations should give a clear and balanced account of what happened based on established facts. Providing a clear account of the facts should include using language that is easy to understand, and which is appropriate to the complainant and their circumstances.
57. The Trust’s complaint response to Mrs O, dated 29 April 2024, provides a detailed account of Ms A’s care. This explanation included a lot of complicated medical terminology with no further explanation as to what these meant. The average reading age in the UK is 9-11 years, and we can understand why many members of the general public would struggle to understand these terms without them being explained in the complaint response.
58. In addition, the paragraphs in the letter were very long, which made navigating the account of Ms A’s care more challenging. There were no breaks between large chunks of text that related to different dates and procedures which took place. This made the response more difficult to understand as the explanation was not broken down into easily understandable paragraphs.
59. Based on the Trust’s complaint response, it appears the Trust’s response fell short of providing a clear account of the facts using language that is easy to understand.
60. With regards to refusing the meet with Mrs O, complaint resolution meetings are offered/held at the discretion of the Trust. That said, our NHS Complaint Standards say that communication should be appropriate to the needs of the complainant. This should include considering whether a face-to-face meeting would help to resolve the complaint.
61. In this case, it would have been helpful to offer a meeting so that Mrs O could ask questions about the medical terminology used in the complaint response. It also would have been an example of good complaint handling. However, we cannot robustly conclude that not doing this indicates service failure.
62. The Trust has agreed to apologise to Mrs O for the impact arising from the missed opportunity to explain her sister’s care in simpler language. We consider this to be a fair and proportionate resolution for a one-off instance of poor service, in line with our NHS Complaint Standards.