Sedation
21. Mrs C is concerned her mother was left sedated for too long after surgery. She told us this led to her deterioration and delayed her mother’s recovery.
22. Mrs R had coronary bypass heart surgery in the morning of 11 November 2022. After the operation she was sedated and placed on a ventilator to help her breathe. At this stage Mrs R was very unwell and the records show she was suffering with multi-organ failure.
23. Over the following week, staff attempted to wean Mrs R from sedation and ensure she was able to be taken off the ventilator which was helping her breath. Staff were unable to successfully wean Mrs R off sedation safely and therefore on 18 November, successfully completed a tracheostomy procedure, where an opening in the neck is made surgically to allow access to the windpipe and help with breathing.
24. After the tracheostomy procedure staff continued attempts to wean Mrs R off sedation and wake her so she could continue her recovery. Mrs R remained agitated and sometimes delirious and pulled at various invasive lines. Staff therefore kept her sedated until she was well enough on 24 November, when the sedation was stopped.
25. Our anaesthetist adviser explained sedation is an essential part of managing critically ill patients, and in this case, Mrs R had undergone major surgery and was very unwell after the operation.
26. The ICS says sedation should be used in intensive care settings to facilitate the use of otherwise distressing treatment, such as ventilation. It also says sedation should be used to control agitation.
27. The same ICS guidance says oversedation can mean patients need artificial ventilation for longer and increase the need for tracheostomy. It also says undersedation and weaning too quickly can cause discomfort and may increase the risk of intolerance to a tracheostomy if needed later. The guidance explains other risks of under sedation such as heart issues, increased oxygen needs and infection.
28. We think it is important to note there is a fine balance between keeping someone sedated and waking them up. In this case, Mrs R was very unwell and needed intensive care and help breathing using a ventilator. The records show when she had breaks from sedation she remained agitated. We have seen evidence the Trust considered the risks of Mrs R being able to pull and remove lines such as the ventilator, which were essential to her treatment between the risk of keeping her sedated for longer.
29. We can also see the Trust tried to wean Mrs R off sedation slowly and gave her sedation breaks. Our anaesthetist adviser explained sedation breaks are an essential part of intensive care management and are important to regularly assess someone’s neurological status and make decisions on whether someone is physically well enough to wean from ventilation.
30. Our anaesthetist adviser also explained that whilst tracheostomies are used to help someone off ventilation, they are not used at an early stage as there is a possibility patients will be able to wean off sedation and ventilation without the need for the tracheostomy procedure. Unfortunately, Mrs R was unable to come off the ventilator and unable to wean off sedation sooner because of her poor health.
31. We know it will have been extremely distressing for Mrs R’s family to see her sedated for a prolonged period. We hope to reassure Mrs C the sedation was in place for as long as necessary until Mrs R could be safely weaned off the ventilator and her agitation had settled.
Tracheostomy and other invasive lines in Mrs R’s neck
32. Mrs C told us she was concerned there were lines, including the tracheostomy line in her mother’s neck which caused discomfort and distress. She also says the lines were changed without appropriate analgesia and caused her mother pain.
33. The records show Mrs R had two invasive lines in her neck after the operation. We have firstly focussed on the care and insertion of the tracheostomy line.
34. The tracheostomy was successfully fitted on 18 November. This line is an invasive tube which is inserted into the windpipe to help with breathing. It is often used to wean someone from a ventilator.
35. We can see Mrs R was still sedated when the tracheostomy procedure was carried out and she was given local anaesthetic for pain control. The records show the procedure went well.
36. The ICS’ guidance on tracheostomy care says the procedure should be carried out to help facilitate weaning from ventilation in an intensive care setting. It also says specialist nursing care needs to be carried out and the site checked regularly.
37. We have seen evidence the tracheostomy site had bled on 18, 19 and 30 November, which matches the family’s recollection of events. On each occasion it was noted there was no active bleeding from the tube, but yellow secretions were seen on 30 November. The dressings were cleaned and changed. Swabs were also taken to check for signs of infection and antibiotics were given.
38. The ICS says patients should be seen by a tracheostomy multi-disciplinary team and the critical care team should be an integral part of this group. It also says active bleeding at a tracheostomy site should be noted and treatment considered.
39. We have seen evidence Mrs R was seen regularly by the multi-disciplinary team, which included nursing staff from the intensive care ward to care for the tracheostomy. The site did not show active bleeding but when blood was noticed staff took action to investigate the reasons for this by taking a swab and ensured the area was clean. In addition, the team also assessed Mrs R regularly to plan weaning off the ventilator and move to the tracheostomy.
40. We have seen nursing staff continued to check the tracheostomy site and regular care of the site is noted in the nursing records and action was taken to ensure the site remained clean.
41. Mrs R also had a central venous catheter inserted into her neck. This is a long tube which can be inserted into someone’s neck and is used for administering medication, fluid or blood.
42. The records show a central venous catheter was inserted into the left side of Mrs R’s neck during the bypass surgery. This took one attempt and was successful.
43. On 25 November staff decided to change the venous catheter as it had been in place for two weeks. The venous catheter was moved to the right side of Mrs R’s neck. We have seen evidence this procedure was successful, and local anaesthetic was given during the procedure.
44. The family told us they visited Mrs R after the venous catheter was moved to the right side of her neck. They told the area was bleeding and causing Mrs R distress. The family said they asked nurses to clean the area.
45. Unfortunately, we cannot see evidence of bleeding from the venous catheter site within the records, and the Trust say it has no recollection of this. Therefore, we are unable to come to a clear conclusion on this matter.
46. On 30 November it was noted Mrs R’s venous catheter was ‘oozing’ so a plan was made to switch it to the left side of Mrs R’s neck. This procedure took place on 2 December and local anaesthetic was given and the procedure went well.
47. NICE guidance on devices used to access veins, such as a venous catheter says a device should be changed if a device is no longer intact or moisture has collected under a dressing, to reduce the risk of infection.
48. We have seen clear records of daily care for the venous catheter, and we have seen evidence staff took action to change the venous catheter site when moisture was noted.
49. Our anaesthetist adviser explained Mrs R received appropriate pain relief in the form of local anaesthetic when the tracheostomy and venous catheters were inserted, and she was sedated. They added the records show effective care took place to monitor the sites once inserted.
50. Taking account of our clinical advice and the evidence, we have seen in the records, we think the Trust acted in line with guidance when looking after both lines in Mrs R’s neck.
51. We found the Trust gave appropriate pain relief during these necessary procedures. We have considered that Mrs R was sometimes sedated for them, however we know that during the times she was being weaned off sedation she was uncomfortable, and it will have been distressing for her family to see this. However, we hope to reassure Mrs C that we have seen regular care took place, staff acted and increased sedation when Mrs R was agitated, and the procedures were carried out in line with guidance to reduce Mrs R’s pain.
Diagnosis and treatment of necrotic tongue
52. Mrs C says her mother’s necrotic tongue was not diagnosed soon enough or treated in a timely way. She says this was distressing and left her mother uncomfortable and unable to recover.
53. Necrosis of the tongue is a rare condition where tissue in the tongue becomes inflamed and infected and dies.
54. Mrs R developed bruising on her tongue on 13 November, which was two days after the surgery. Our nurse adviser explained this is a sign of poor blood flow to tissues and organs in the body and this can happen in patients requiring maximum support. They also explained the bruising could have been exacerbated by Mrs R potentially biting her tongue.
55. Once the bruising was noted nurses applied ointment to Mrs R’s tongue and it was assessed daily. Nurses also used wet sponges on her tongue and cleaned her teeth.
56. On 16 November a black mark was noted and an incident was raised. Mrs R was referred to the tissue viability nursing team for specialist monitoring. The team saw Mrs R on 17 November and thought she was biting on her tongue at the front and left sides, which was causing further damage. The tissue viability nurse said the top of Mrs R’s tongue was necrotic and recommended the continuation of regular mouth care and oral gel. They also recommended the use of a bite guard and said staff should record and monitor further damage.
57. We can see staff attempted to use a bite guard, however Mrs R was unable to tolerate this so decided to discontinue its use. Our nurse adviser explained in some situations a bite guard can worsen the damage if someone is unable to tolerate it.
58. Staff also continued daily oral hygiene and monitored Mrs R’s tongue. On 28 November, Mrs R was referred to the maxillofacial team for further guidance on the management of her tongue. The team recommended continuing with the current treatment and she was reviewed again on 29 November, 1, 2 and 3 December. Another gel was recommended to help with pain relief and doctors considered removal of the necrotic tissue if there was no improvement.
59. The British Association of critical care nurses says oral assessments should take place in ventilated patients and should look at the tongue, lips, teeth, gums and soft tissues. It says oral cleansing should take place with moisturisation of the mouth and teeth should be brushed. It also says oral care assessments should be carried out every 12 hours.
60. The NMC says nurses should make timely referrals to other practitioners when care is required and asked for help from suitably qualified colleagues.
61. Our nurse adviser explained necrosis of the tongue is a rare condition but generally occurs when there is low blood pressure to multiple organs. They added that in patients requiring maximum support to maintain function of their heart, lungs and kidneys there is a high probability of poor blood flow to the head and neck, and this can cause tongue necrosis.
62. We have noted the extent of the injuries to Mrs R’s tongue, and we do not doubt the necrosis of her tongue would have been very uncomfortable for her. However, we have seen clear evidence of continued oral care, and we can see nurses referred Mrs R to specialists in a timely manner. The specialist teams all advised to continue with the care nurses on the ward were already providing and therefore we do not think different treatment would have changed the outcome for Mrs R. We hope to reassure Mrs C that we have seen evidence nurses provided appropriate oral care to treat Mrs R’s worsening symptoms and ensure her pain was managed.
Blood clot
63. Mrs C complains her mother developed a blood clot which could have been avoided and potentially led to a brain haemorrhage. She also says the family were not told about the seriousness of the blood clot.
64. Patients who are largely immobile after major surgery are at an increased risk of developing deep vein thrombosis (DVT), which is a condition where a blood clot forms in a deep vein and can be serious.
65. Following Mrs R’s surgery, she was assessed as being at high risk of DVT. Dalteparin (a blood thinning medication) was prescribed and given at a dose of 2500units.
66. On 26 November, doctors noticed Mrs R’s left-hand fingers were mottled. A doppler ultrasound was ordered (a scan to show blood flow through the cardiovascular system) and dalteparin was given.
67. On 27 November the doppler ultrasound was carried out and confirmed DVT. Following this diagnosis the records show the dose of dalteparin was increased to 4000 units, twice daily.
68. NICE guidance on venous thromboembolism says risk assessments should be carried out to identify the risk of patients developing DVT. It also says to consider low-molecular-weight heparin (LMWH) medication to patients having cardiac surgery. LMWH medication is used to prevent blood clots and also used for the treatment of DVT.
69. The BNF says an initial dose of 2500 units of dalteparin should be given before surgery and 8-12hours after surgery. It says after this period 5000units should be administered every 24 hours in patients who are high risk of developing DVT.
70. The same BNF guidance says dalteparin can be increased to a maximum of 18,000 units daily in patients that have been diagnosed with DVT.
71. We have seen evidence Mrs R was given dalteparin before and after surgery to reduce the risk of developing DVT. She was continually monitored for signs of DVT and we think the Trust acted at the earliest opportunity when it saw signs of DVT. We also hope to reassure Mrs C that the Trust administered a higher dose of dalteparin when the DVT was diagnosed, and this was in line with guidance.
72. We cannot say whether the blood clot could have been avoided, as Mrs R was already at high risk of developing DVT even with medication. We also cannot say the blood clot caused the brain haemorrhage.
73. We have thought about whether the Trust communicated the seriousness and potential impact of the DVT when it was diagnosed.
74. The GMC says doctors should give support and information to those close to a patient. It also says doctors should check the understanding of the information given.
75. We can see the family visited Mrs R regularly. Specifically, we can see the family visited Mrs Ron 27 November after DVT had been diagnosed. Nurses noted ‘updates’ had been given but there is no detail about what information was given. Therefore, we cannot say for certain what information the family were given about the DVT.
76. In its complaint response, the Trust apologised the family were not informed about the blood clot and says it has discussed the importance of communication with colleagues.
77. We have considered what Mrs C told us about the communication regarding this diagnosis. With the lack of recorded notes, on balance we think the Trust may not have been clear about the seriousness of the DVT and blood clot. However, we have seen the Trust has apologised for this and we are satisfied it has taken action to address the importance of communication.
Diagnosis of brain haemorrhage
78. Mrs C complains a CT scan was not carried out soon enough. She says earlier diagnosis of the brain haemorrhage may have meant it was treatable.
79. On 2 December at 00.55am Mrs R was noticed to be weak and lethargic. It is noted she could move all limbs, and she was assessed as having a Glasgow Coma Scale (GCS) score of 15/15. Mrs R communicated with nurses throughout the night using a whiteboard and pen but reported feeling sick in the morning.
80. The GCS scoring scale is a neuroglial scale used to assess a patient’s level of consciousness. The score ranges from 3-15 and a lower score can indicate a serious condition.
81. At 10am on 2 December, Mrs R’s GCS score was noted to be 13 and her sickness had got better. Mrs R was still engaging with staff during 2 December.
82. On 3 December Mrs R was seen by a doctor at 16.56 who noted she was drowsy, and her GCS score had dropped to 3. Staff ordered an urgent CT scan of the brain. A CT scan took place at 18.36pm and showed a severe multicompartmental intracranial haemorrhage. This is a rare condition where a blood leaks out of a blood vessel into the brain tissue.
83. Staff at the Trust spoke to specialist neurologists at a different trust who explained that sadly the haemorrhage was untreatable because of the severity of the brain injury it had caused.
84. The family were informed of the diagnosis and further testing of Mrs R’s brain stem was carried out over the following two days. However, the haemorrhage was not survivable, and Mrs R sadly died on 5 December.
85. We have considered NICE guidance on diagnosis of strokes because it gives guidance on when to act on changing neurological symptoms. The NICE guidance says CT scans should be carried out as soon as possible and within 24 hours of symptom onset in patients with a GCS score of less than 12.
86. We can see the Trust acted immediately when Mrs R’s GCS score dropped dramatically from 13 to 3 and ordered a CT scan. We have not seen evidence a CT scan should have been carried out sooner. We are also unable to link the blood clot to the brain haemorrhage as haemorrhages can be spontaneous. The medication used to treat the blood clot/DVT was necessary at the time.
87. We are sorry that Mrs R suffered a devastating brain haemorrhage which caused her death, and we know this will have been a shock for her family. We hope to reassure Mrs C the Trust took action immediately and in line with guidance and we have not seen evidence the haemorrhage could have been prevented or treated.
88. We know this was an extremely distressing time for Mrs C and her family and we acknowledge the impact Mrs R’s death has had on the family. We hope our report has provided explanations and reassurances to the family that the Trust treated Mrs R in line with guidance.