16. 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.
Complaint about the NG feeding tube
17. GMC guidance says doctors should promptly provide or arrange suitable advice, investigations or treatment where necessary.
18. The NICE guidance explains people requiring tube feeding should have their tube inserted by healthcare professionals with the relevant skill and training. The position of all NG tubes should be confirmed after placement with an abdominal x-ray.
19. NHS Improvement guidance explains the importance of placement checks to confirm the NG tube is correctly placed before any liquids are put down the tube. Patients would not usually display normal reflexes of choking or coughing if a tube is incorrectly placed. If the tube is in the wrong place fluids could pass into the respiratory tract. Deterioration in a patient’s condition is not always immediate so there may not be obvious symptoms for some hours.
20. On 13 April a speech and language therapist (SALT) assessed Mr S and found he was not safe to have oral intake due to high and likely risk of aspiration. This is where something other than air enters the airway. He therefore needed to be fed with an NG tube.
21. The records show that over the next few days staff inserted NG tubes on several occasions. Unfortunately, Mr S either pulled these out or X-rays confirmed they were in the wrong position, so had to be re-inserted.
22. Staff also used a nasal bridle (a length of gauze with two small probes which go behind the septum, the structure in the middle of the nose) to hold the tube in place and put mittens on Mr S try to prevent him pulling tubes out.
23. We recognise Mrs S’s view that x-rays should have been done straight after the tube insertion, and that tubes should have been reinserted immediately when pulled out. Unfortunately, this is not always possible depending on the availability of staff and X-ray capacity.
24. There may not always be a doctor experienced and skilled in NG tubes available immediately. X-rays must be prioritised by radiology department when considering the needs of all patients from all areas of the hospital.
25. When Mr S pulled a further NG tube out on 16 May staff decided not to re-insert the tube and the plan was to move to total parenteral nutrition (TPN) feeding. This is a method of feeding that bypasses the digestive system, providing essential nutrients directly into the blood stream.
26. This involves the insertion of a catheter into a large vein near the heart, which comes with risk of major complications. Due to the risk of this procedure, the plan was to do this after the weekend.
27. However, on 19 April after the weekend, Mr S seemed calmer and therefore, staff agreed to have one more attempt at an NG tube. Staff did so, completed X-ray checks and then commenced feeding on 20 April. This continued until 21 April when Mr S pulled the tube out again.
28. However, by this time, SALT had assessed Mr S again and considered he was suitable to restart oral intake with some modification to food. As such, an NG tube was not reinserted.
29. From what we have seen, we have not seen any significant periods of delay in relation to the NG tube or assessments for oral feeding. We think the Trust was acting in line with the GMC guidance, NICE guidance, and NHS improvement guidance.
Complaint about staff stopping antidepressant medication
30. GMC guidance says doctors must prescribe drugs only when they have adequate knowledge of the patient’s health and are satisfied the drugs or treatment serve the patient’s needs.
31. Pharmaceutical guidance says records should be kept of all medications administered or withheld as well as those declined. If not administered, the reason should be included in the record and where appropriate the medical team is notified.
32. On admission, doctors prescribed sertraline to Mr S, as this is a medication he had been taking before admission. However, it was withheld initially due to him having difficulty swallowing.
33. The Formulary explains sertraline is only available in oral preparation. This means there is no alternative means of administering the medication if a person cannot have anything orally or does not have alternative feeding access.
34. Our adviser said there is no substitute for sertraline in this scenario. In some situations, doctors may continue with some essential oral medications. However, sertraline is not considered an essential medication and Mr S had a severe swallowing impairment so was at high risk of aspiration.
35. Once an NG tube and oral intake was established, on 20 April a doctor then prescribed sertraline at a reduced dose, having taken advice from pharmacists. This was because Mr S had been without sertraline for several days and he also had some impairment of his liver. The Formulary advises caution with this medication in those circumstances.
36. The prescription planned to increase the dosage back to his pre-admission level over a four-week period. This plan was in line with the Formulary which says to increase in steps of 50mg at intervals of at least a week.
37. The records show nursing staff administered sertraline to Mr S on 20, 21 and 22 April. There are no records indicating it was administered again until Mrs S raised concerns on 5 May. At that time, the doctor re-prescribed the medication with the same plan to increase the dose. Nursing staff then administered it to Mr S each day until discharge.
38. This means Mr S was without sertraline medication from 23 April to 4 May inclusive. During this time, nursing staff did not document any reasons for omitting it and we have seen nothing to indicate they informed the medical team that it was not being administered. This is not in line with the pharmaceutical guidance and is an indication of a failing.
39. 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.
40. We can see Mrs S raised the concern with a doctor due to her husband’s low mood. There are other entries in the nursing records that Mr S was low in mood.
41. The RCPsych website explains that between a third and half of people who take an antidepressant will experience withdrawal symptoms to some extent, and the risk seems to be greater if they have taken a high dose for a long time. Patients are more likely to get these symptoms, and for them to be worse, if they stop taking an antidepressant suddenly or if the dose is reduced quickly.
42. We know on admission to hospital Mr S was taking the maximum dose of sertraline and that it was necessary to stop this suddenly as he was nil by mouth. This meant Mr S was unavoidably at higher risk of withdrawal symptoms. The RCP antidepressant guidance lists symptoms of antidepressant withdrawal, which includes several related to mood.
43. Any low mood Mr S experienced initially, was unavoidable, as it was necessary for his safety to stop sertraline at the start of his admission.
44. The RCPsych website says withdrawal symptoms usually improve quickly, in days or even hours, if the antidepressant is restarted. This means that if sertraline had been administered consistently from 20 April, his withdrawal symptoms would likely have improved reasonably quickly.
45. Unfortunately, as it was omitted from 22 April to 4 May, this would have prolonged the unpleasant withdrawal symptoms Mr S was experiencing. This means there is indication that not giving Mr S sertraline had a negative impact on him. We also accept that seeing this was distressing for Mrs S, who was worried about her husband’s very low mood.
46. We raised what we have seen with the Trust. It has agreed to write to Mrs S to acknowledge the omission of sertraline and the impact this had on them both. As this is the outcome sought by Mrs S, there is nothing further for us to do. We consider this is an appropriate resolution.
Complaint about discharges from hospital
47. The DOH discharge guidance says every person on every general ward should be reviewed for discharge. If they do not meet any of the listed criteria, doctors should consider discharging the patient to a less acute setting.
48. The listed criteria are that they do not require intensive care, oxygen therapy, intravenous fluids or medication and have not recently undergone certain procedures in the previous days. They should not be in the last hours of their life or have functional impairment beyond what can be provided in the community.
49. Their national early warning score (NEWS) should not be greater than 3. The RCP guidance explains NEWS is scoring system in which a score is allocated to physiological measurements. The total score indicates the level of clinical risk.
9 May 2022
50. The records show doctors assessed Mr S regularly and considered he was medically optimised for discharge from 27 April. He remained that way up to and including 9 May.
51. On that day, a consultant and senior doctor reviewed Mr S. They found his chest was clear, he was alert, and they noted his physiological measurements. He had a normal breathing rate, temperature, pulse rate and oxygen saturation level. His blood pressure was only slightly raised giving him a NEWS score of 1.
52. They considered he was fit for discharge and, as a place was available for him at a care home, he was discharged there that day.
53. Our adviser said Mr S’s blood test results did not indicate he had an infection when he was discharged. We can also see his physiological observations do not indicate he was systemically unwell.
54. We acknowledge Mrs S says her husband had green sputum and, concerned this meant he had infection, she showed this to staff. Although this is not documented in the records, it appears from the Trust’s response that staff planned to discharge Mr S with antibiotics to cover him in case of infection.
55. Our adviser said that although Mr S’s frailty and medical conditions did put him at risk of developing an infection or illness at any time, this alone is not a reason to keep a patient in hospital.
56. We can see that, in line with the guidance, the Trust considered whether it should discharge Mr S. He did not meet any of the criteria set out in the DOH discharge guidance and there was no indication he needed to stay in hospital.
57. We note that although the Trust planned to discharge Mr S with antibiotics, it did not do so. In its complaint response, the Trust acknowledged and apologised for this. We considered whether there was a clinical impact of this, such as a need for readmission or deterioration in health and could not see one.
58. The day after Mr S was discharged the care home contacted his GP who saw him the next day and prescribed antibiotics. The GP was willing to see and review Mr S again if required. The GP records show Mr S completed the seven day course of antibiotics while at the home and there was no further contact with the GP regarding this.
59. As there was no clinical impact on Mr S, and the Trust has already provided the acknowledgment and apology Mrs S seeks, there is nothing further for us to consider here.
5 September
60. The records show Mr S did not meet any of the reasons to remain in hospital, as set out in the DOH discharge guidance at paragraphs 47 and 48.
61. During his admission staff had treated him with two courses of antibiotics for episodes of infection. There were no clinical signs he had active infection at the time he was discharged. Mr S’s NEWS score was 0, meaning all his physiological observations were normal.
62. Our adviser said his blood tests were normal and there was no indication he was unwell on the day of discharge. Although Mr S had several medical conditions, was frail and with impaired swallowing, these are chronic issues that should be managed in the community, with admission for hospital-based treatment only when required.
63. We acknowledge Mr S was readmitted a few days later. However, this does not mean the decision to discharge him on 5 September was incorrect if he had no reason to remain in hospital. We have seen no indication of a failing here.
22 September
64. On this occasion, Mr S had been in hospital for 13 days during which he had a seven day course of intravenous (IV) antibiotics.
65. Doctors considered he was medically fit for discharge from 16 September. A doctor explained to Mrs S that this was because her husband did not require oxygen, did not have a temperature, inflammation markers in his blood had improved significantly and he was better in himself. They explained that sadly with him being ‘risk fed’ (meaning he was allowed to receive oral food and fluid at a consistency which was less than ideal for him) it was likely he would have recurrent chest infections in the future.
66. On 20 September a doctor reviewed Mr S and noted he had a chesty cough and a raised heart rate. On listening to his heart, there were no abnormalities in its functioning. They considered he may have aspirated again so the plan was to commence IV antibiotics and fluids and for chest x-ray.
67. The following day, a consultant examined Mr S and noted the chest x-ray showed his lungs were clear, heart sounds were normal. The consultant therefore stopped IV antibiotics and concluded Mr S was fit to be discharged.
68. The records show Mr S’s NEWS was 3 indicating he was at low clinical risk, according to the RCP guidance. We can see that he did not meet any of the reasons to remain in hospital as set out in the DOH discharge guidance at paragraphs. Our adviser said there was nothing to indicate Mr S required further inpatient treatment.
69. We have seen no indication Mr S there was anything wrong in the Trust’s decision to discharge Mr S. Therefore, we will take no further action.
70. In summary, we will not take Mrs S’ complaint further. We hope our consideration of her complaint provides Mrs S with some closure to her concerns.