South Tyneside and Sunderland NHS Foundation Trust

5. Mrs A complains the South Tyneside and Sunderland NHS Foundation Trust (Trust) ignored her husband, Mr A’s wishes to be re-intubated on 13 and 16 January. She says when her husband’s wishes changed the Trust did not discuss this with him and was told it was no longer an option. She says when the extubation happened it should have been carried out by a consultant and not a nurse. She also says delays in extubating her husband on 28 December 2022 led to Pseudomonas, leading to a longer period on the ventilation.

6. As a result, she says her husband died due to the actions of the Trust. She says the family was left heartbroken and upset, and she says she was denied the last period of Mr A’s life together.

7. She is seeking an apology, service improvements (in respect to the palliative care team) an acknowledgement of failings and some form of financial compensation.

8. On 17 December 2022, Mr A was admitted to the Trust with increased left sided tongue swelling, odynophagia (painful swallowing) and dysphagia (difficulty swallowing). The Trust carried out a CT scan and surgery to remove infected tissue (Ludwig’s Angina) from the base of his tongue

9. Following this the Trust made the decision to ventilate and sedate Mr A in its intensive care unit (ICU).

10. On 19 December, the Trust failed in its attempt to extubate (removal of ventilation tube) Mr A. It was documented this failed due to respiratory tract secretions (the buildup of fluids like saliva and mucus in the airways) and a poor cough.

11. The Trust carried out a CT scan of Mr A’s neck and chest the following day.

12. On 21 December, the Trust successfully extubated Mr A. However, the clinical notes suggest the Trust took Mr A to theatre over concerns it had regarding his airways and a deterioration in his health (hypoxia (lack of oxygen) and drowsiness).

13. The Trust readmitted Mr A to ICU and ventilated him again. It also prescribed antibiotics.

14. On 22 December, the Trust attempted to extubate Mr A which failed again. This was due to hypoxia. Mr A was noted as feeling distressed and being unable to breathe. The Trust made the decision to reintubate once again.

15. On 23 December, the Trust carried out a bronchoscopy (a medical procedure where a thin, flexible tube with a camera (bronchoscope) is inserted into the lungs to visualize and examine the airways). This found occlusive secretions right upper and intermediate bronchus. (obstruction in the upper right portion of the respiratory tract and right bronchus, likely due to thick or excessive mucus). The records also show Mr A had developed an infection in his lunges (Pseudomonas (common infection in individuals with cystic fibrosis (CF) and those with weakened immune systems)). The Trust prescribed, Tazocin (a specific type of antibiotic).

16. On 24 December, the Trust planned to transfer Mr A to a different hospital for extubation and then for him to be sent home with ventilation input.

17. The following day, while still at the Trust, it is documented that Mr A was suffering ongoing pain and still suffering from Ludwig's angina (a serious and rapidly progressing bacterial infection of the soft tissues in the floor of the mouth and neck).

18. The Trust has said in its complaint response that the transfer to the different hospital did not happen as a bed could not be facilitated and as such it changed its plans to carry out future extubation at the Trust.

19. On 30 December 2022, the Trust unsuccessfully tried to wean Mr A off ventilation.

20. On 4 January 2023, it appears the Trust had detailed discussions about the implications of a tracheostomy (a surgical procedure that creates a hole in the neck, directly into the trachea (windpipe), to facilitate breathing).

21. On 6 January, the Trust once again tried to wean Mr A off ventilation, but this appeared to have failed.

22. On 10 January, Mr A self-extubated (pulled the tube out himself) but it is unclear whether this was accidental or not. The Trust intubated.

23. On 16 January, the Trust extubated (with no plan to reintubate) Mr A and, following this he tragically died.

24. The coroner’s report listed Mr A’s cause of death as Respiratory failure, Motor neurone disease and chronic obstructive pulmonary disease. The conclusion of the coroner as to the death, was complications of extubation.

25. An inquest into Mr A’s death was held on 2 August 2023. Mrs A has said during the inquest the family were told that Mr A could have been intubated and therefore would not have died. This lead them bringing the complaint to us.

Decision of the Trust to extubate Mr A on 16 January 2023 and not to re-intubate (including issues surrounding communication)

29. Mrs A told us that the Trust ignored Mr A’s wishes to be re-intubated prior to being extubated on 16 January and she says had it re-intubated her husband, he would not have died.

30. Firstly, the records show on 13 January Mr A attended a consultation where reintubation was discussed with the ICU consultant and ICU nurse.

31. During the consultation Mr A and the Trust agreed that the plan was for Mr A not to be re-ventilated should extubation be unsuccessful.

32. The Trust offered the opportunity to discuss further what would happen if extubation wasn’t successful, but Mr A did not wish to discuss it at this time. The Trust has said previous conversations had taken place about potential consequences if extubation didn’t succeed.

33. Furthermore, on 16 January 2023, the Trust discussed the plan to remove the ventilation tube with Mr A. He reiterated his understanding that he would not wish to have a tracheostomy (and indeed this would not be medically viable).

34. Mr A communicated that if the wean did not go to plan, that he would want the tube to be replaced. It was explained that this would not be possible (as it would not be a treatment with a reasonable chance of restoring a quality of life that the Trust deemed to be acceptable.

35. It appears Mr A understood that if extubation was unsuccessful he knew he would likely die. It was documented that Mr A was anxious during this conversation.

36. Prior to extubation on 16 January 2023, the Trust had unsuccessfully extubated Mr A on three different occasions.

37. Our adviser explained following extubation the Trust would have needed to reintubate Mr A, given past attempts had been unsuccessful, and Mr A would not have been able to breathe unaided.

38. Our adviser explained had the Trust reintubated Mr A he would have required a tracheostomy, which Mr A had insisted he did not want. Without the tracheostomy Mr A would not have been able to breathe and would have died without ventilatory support.

39. The evidence shows there were extensive discussions with Mr A and his family (6 & 18 December 2022 and 5 & 13 January 2023) about the need to perform a Trachestomy as Mr A would not have been able to breathe without support.

40. GMC guidance “Treatment and care towards the end of Life” Section 10 state:

‘Following established ethical and legal (including human rights) principles, decisions concerning potentially life-prolonging treatment must not be motivated by a desire to bring about the patient’s death and must start from a presumption in favour of prolonging life. This presumption will normally require you to take all reasonable steps to prolong a patient’s life. However, there is no absolute obligation to prolong life irrespective of the consequences for the patient, and irrespective of the patient’s views, if they are known or can be found out’.

41. section 40 ‘weighing the benefits, burdens and risk’ state:

‘The benefits of a treatment that may prolong life, improve a patient’s condition or manage their symptoms must be weighed against the burdens and risks for that patient, before you can reach a view about whether it could be in their interests. For example, it may not be in a patient’s interests to provide potentially life prolonging but burdensome treatment in the last days of their life when the focus of care is changing from active treatment to managing the patient’s symptoms and keeping them comfortable’

42. Our adviser explained discussions were in line with GMC guidance as there was no indication Mr A did not have mental capacity to make decisions on his own health. He was also satisfied the Trust acted appropriately in its decision making and weighing up what the best interests of Mr A were.

43. He explained it would appear over the Christmas and New year period the focus of the Trust was on weaning Mr A from ventilator, reducing pseudomonas secretion burden, treating his infection with antibiotics and communicating with Mr A and his family.

44. Our adviser said the decision to extubate on 16 January was an appropriate clinical decision. The evidence shows extensive discussions took place which involved multiple Intensive Care Consultants, long term ventilation team and the palliative care team. Mr A sadly did not have the capacity to breathe and therefore stay alive without a tracheostomy or ventilatory support. He explained staying on a ventilator was not in Mr A’s best interests.

45. As such, although there is no doubt the circumstances surrounding Mr A’s death were extremely upsetting and distressing for Mr A’s family, the action of the Trust not to re-intubate Mr A on 16 January were appropriate. This is because; it could not reintubate Mr A indefinitely and given he did not wish to have a tracheostomy, which was required to breathe unaided.

Mrs A has also questioned the decision of the Trust to allow a nurse to extubate Mr A on 16 January 2023

46. It is widespread clinical practice for nurses to extubate patients in intensive care after a medical decision has been made. Although there are no specific guidelines to state this is the case, Nursing standards guidance - clinical skills, a care plan approach to nurse led extubation, outlines how nurses should extubate patients. This is a clear indication nurses can extubate.

47. As such, we have seen nothing to indicate the decision to allow a nurse to extubate Mr A to be inappropriate.

Decision of the Trust not to extubate Mr A around 28 December 2022

48. Mrs A has said the decision not to extubate Mr A around 28 December led to him contracting pseudomonas (infection) and led to him being longer than necessary on ventilation.

49. We discussed this with our adviser, who explained there is no indication that had extubation happened it would have been successful. As previously explained extubation had been unsuccessful on three separate occasions.

50. Our adviser explained keeping Mr A on a ventilator would not have been in his best interests, but ultimately staying on the ventilator would have made no difference to Mr A’s health and did give him an opportunity of improving.

51. Keeping Mr A on a ventilator allowed the Trust the opportunity to have difficult discussion with Mr A and his family about the long-term prognosis. We can understand how distressing these discussions would have been for Mr and Mrs A.

52. Our adviser also noted keeping Mr A on ventilation did not result in him contracting pseudomonas as he already had it, as evidenced in the clinical records dating back to 19 December 2022. We are satisfied the Trust’s actions were appropriate in respect to not extubating Mr A in late December 2022.

53. There is no doubting the distress and upset Mrs A says she has experienced because of the Trust’s actions and due to the tragic circumstances surrounding her husband’s death. We would like to thank her for highlighting her concerns and hope she is reassured the Trust acted appropriately.

1. We have carefully considered Mrs A’s complaint about South Tyneside and Sunderland NHS Foundation Trust (the Trust). We have seen no indications of failings relating to her husband, Mr A’s care and treatment.

2. We understand this was a tragic experience for Mrs A and her family, given how poorly Mr A was at the time and the circumstances surrounding his death. We appreciate the family feel the Trust should have done more to prevent Mr A’s death, but we have seen no evidence to suggest this was the case.

3. From the evidence we have considered, we do not see anything to indicate the Trust wrongfully extubated Mr A or failed to appropriately communicate with the family during his time in hospital. We are satisfied the decision not to reintubate Mr A on 16 January 2023 was the appropriate one.

4. For these reasons, we do not propose to investigate further.