Getting COVID-19 while in hospital
17. Before we decide if we should do 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 signs that something has gone wrong.
18. Mrs L says staff at the Trust were not following COVID-19 precautions and did not always use PPE (Personal Protective Equipment). She recalls during one of the video calls with her husband he was being taken care of by a nurse who was wearing their mask down on their chin.
19. The Trust says Mr L was admitted to the AAU (Acute Assessment Unit) which is a COVID-19 protected ward. However, Mr L tested positive for COVID-19 on 26 January and all measures were taken to reduce the risk of transmission of COVID-19. It said staff are regularly tested and follow infection control standards such as good hand hygiene and correct usage of PPE. It said it was a very rare experience that Mr L got COVID-19 on AAU and the Trust has apologised for this.
20. We can see from the records staff tested Mr L for COVID-19 when he was first admitted to hospital and the results came back on 14 January as negative. He had a further COVID-19 test which also returned as negative on 19 January.
21. NHS England issued guidance on 24 April which required trusts to test all patients who were admitted overnight even if they had no symptoms of COVID-19. It also asks trusts to begin identifying patients as possible COVID-19 cases who need to be admitted while they waited for a test result. It says that infection control should be followed as soon as possible. This guidance came into power from 27 April.
22. All new patients at the time, including Mr L, had a PCR (the polymerase chain reaction test) swab taken on admission. The Trust did this to identify COVID-19 at the earliest possible point and keep these patients separate.
23. The medical records show staff tested Mr L for COVID-19 regularly, as test results were returned on 26 and 31 January and 4, 8, 9 and 15 February 2021.
24. The Trust provided us with its policy on isolation of patients which was in use at the time of Mr L’s admission. This refers to the use of a single room to help prevent the spread of COVID-19.
25. We can see that when Mr L’s condition got worse, the Trust completed a COVID-19 risk assessment to assess whether it was safe for Mrs L to be able to visit.
26. We do not consider we can realistically say when and how Mr L caught COVID-19. We find even appropriate infection control procedures cannot eliminate the risk of a patient catching COVID-19 as it is a very infectious disease.
27. Based on the evidence available, it does show the Trust acted in line with the NHS COVID-19 testing guidance at the time. The Trust tested patients for COVID-19 upon admission to hospital and continued to regularly test patients during admission. It also followed its own isolation policy.
28. We have not found any signs of failing. We acknowledge Mr L did contract COVID-19 while admitted to hospital and understand this was distressing for Mrs L.
The treatment of Mr L’s condition was not good enough
29. Mrs L says her husband developed confusion while in hospital and was told by staff at the Trust that this was due to hepatic encephalopathy (HE is a high level of toxins in the blood caused by liver damage). She says her husband had no signs of the condition before he was hospitalised.
30. She says he was not just confused, he had a completely different reality to what the situation was, for example, he thought he was in a hotel not a hospital.
31. The Trust says Mr L had Grade 2 HE which affects the function of the brain. It says the development of encephalopathy can happen very suddenly without any warning.
32. The Trust says Mr L’s HE had resolved completely from treatment by 18 January so that on 19 January he was able to remember he had fallen.
33. Our adviser said one of the most important functions of the liver is to remove toxins from your blood. If the liver is unable to do this the levels of toxins in the blood increase which causes symptoms such as confusion.
34. The medical records show the Trust arranged an endoscopy (a test with a small camera) which showed that he had oesophageal varices (abnormal veins in the food pipe that connects the throat and stomach).
35. The medical records also show Mr L was treated with antibiotics and anti-fungal medication.
36. The records show Mr L developed acute kidney injury and hyperkalaemia (high potassium) which was treated with hemofiltration (a form of therapy for the treatment of end stage renal failure).
37. The medical records also show a range of electrolytes (salts and minerals) were given to Mr L following blood test results.
38. We can also see Mr L received mechanical ventilation and required sedating to tolerate periods of prone ventilation (mechanical ventilation with the patient lying face-down).
39. We have reviewed The British Liver Trust’s website ‘Hepatic Encephalopathy (HE)’. It provides a patient guide to understanding advanced liver disease. It advises:
‘The first step is to identify what has caused the episode of HE and treat it. This could include: • Stopping bleeding (varices) in the stomach, bowel (intestine), or food pipe or gullet (oesophagus) • Treating infections • Treating kidney failure • Treatment to get levels of salts and minerals (electrolytes) in the blood back to normal • Providing life support if the person is in a coma’
40. We find that the Trust provided all of these recommended treatments to Mr L in order to treat his condition.
41. In addition to this, The British Society of Gastroenterology says:
‘Recurrent hepatic encephalopathy is a significant complication of cirrhosis that has a huge impact on patients’ quality of life. Most patients can be effectively managed by treatment with lactulose and rifaximin and good education.’
42. We can see the Trust acted in line with these guidelines as the medical records show Mr L also received lactulose, enemas and rifaximin.
43. We find the Trust treated Mr L’s HE in line with the relevant guidelines by trying multiple different treatments available. We have found no sign of failing by the Trust in the treatment provided to Mr L for HE.
44. We hope this is reassuring for Mrs L to read.
The Trust did not manage Mr L’s fall risk
45. Mrs L says Mr L had multiple falls due to incomplete processes and inadequate measures taken.
46. Mrs L says a risk assessment done on 16 January was not fully completed and did not include information about Mr L’s increasing confusion.
47. The Trust says an initial falls risk assessment was undertaken on 12 January, within 24 hours of admission. The risk assessment identified Mr L was unsteady on his feet and anxious about falling. The assessment also identified Mr L needed assistance with any type of moving, which was put in place for him.
48. There were repeated falls risk assessments on 16 and 19 January.
49. The Trust says Mr L had a fall on 19 January where he fell forward and hit the left side of his head and was identified as a falls risk. The Trust says a CT head scan was done and did not show any further injury. Following this, nursing staff placed falls mats around the bed and continued to monitor Mr L in a bed that was visible from the nursing station to allow for maximum observations.
50. The Trust says on 26 January Mr L stood up from the bed and stumbled. The Trust says this was seen by a nurse who helped Mr L to lower himself to the floor to reduce the risk of causing further harm.
51. The medical records show evidence of the two falls Mr L had while in hospital. We can also see evidence that Mrs L was contacted after the first fall.
52. NICE guidance, ‘Falls in older people’ says that this category of patients require risk assessments for falls.
53. Mr L did have risk factors such as confusion and we can see in the medical records that he had a risk assessment upon admission to hospital. There is also evidence that this risk assessment was repeated.
54. Within the same NICE guidance, it says:
‘1.1.3.2 Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function.’
55. In the medical records we can see some of the documentation was incomplete, however, we can see that all factors of a risk assessment were completed and put in place for Mr L.
56. Our adviser said a falls risk assessment, plan of care and regular evaluations are required. They said from the notes it is clear that the team were assessing, planning, delivering, and evaluating care in line with best practice.
57. Our adviser said there is evidence in the records that Mr L had risk assessments, plans of care, and then when he fell, he received interventions such as medical reviews, increased observations, and increased visual observations to prevent harm.
58. We find the Trust acted in line with guidance to manage Mr L’s falls risk and once he had fallen, this was reassessed and observations were increased. We have found no sign of failing.
The communication regarding Mr L’s falls was poor
59. Mrs L says she was told about the first fall her husband had while in hospital, however she only found out about the second fall in the response from the Trust when she raised her complaint.
60. In the final response letter the Trust advised Mrs L was informed of the first fall after it happened on 19 January but has apologised that she was not informed of the fall on 26 January.
61. Our adviser said there is no guidance on informing next of kin about falls but it is accepted practice to do so, especially with a patient who is confused. The records show contact was made on the 19 January, which is good practice.
62. We find the Trust could have told Mrs L of her husband’s fall on 26 January. As Mr L was lowered to the floor with assistance, the Trust staff may not have considered this as a fall at the time.
63. Our ‘Principles of Good Complaint Handling’ say that to put things right organisations should provide an apology, explanation, and an acknowledgement of responsibility.
64. The Trust provided Mrs L with an explanation of how the second fall happened and an apology for her not being told at the time.
65. We find the explanation and apology provided by the Trust enough to put right the impact of her not being aware of the second fall at the time.
The Trust potentially used sedatives incorrectly
66. Mrs L says she is concerned the Trust might have given her husband sedatives which caused mental confusion and rapidly deteriorated his overall condition.
67. The Trust says staff initially gave Mr L oxazepam (a sedative drug) to prevent alcohol withdrawal.
68. The records show that part of the team caring for Mr L included a pharmacist who reviewed his medications and provided advice on their use.
69. Our adviser said the sedative Mr L was given is not known to cause further damage to the liver or symptoms.
70. The National Library of Medicine, ‘Oxazepam’ states:
‘As with most benzodiazepines, oxazepam therapy has not been associated with serum aminotransferase or alkaline phosphatase elevations, and clinically apparent liver injury from oxazepam has not been reported and must be very rare, if it occurs at all.’
71. Based on the evidence available, we have been unable to find any sign of failing in the Trust’s decision to give oxazepam to Mr L and find this would not have caused further damage to his liver or symptoms. We find the confusion was caused by the HE condition Mr L developed.
The Trust did not invite her to see her husband before 17 February 2021 when his blood pressure dropped
72. Mrs L says she was not allowed to stay with her husband or visit him due to COVID-19 restrictions. She says her only way of communicating with him was via phone or video calls.
73. In the final response letter, the Trust apologises for Mrs L not being allowed to visit or stay with her husband at first. The Trust says it was following NHS England guidance at the time on restricting visits by family due to COVID-19.
74. The Trust says when Mr L’s condition got worse, this was reassessed and she was then allowed to visit at set times.
75. The medical records show Mr L had a sudden deterioration on the 17 February and the Trust urgently contacted Mrs L and worked through a risk assessment to enable her to visit her husband. The medical records show Mrs L visited her husband in hospital on 18 February.
76. The records show Mr L continued to deteriorate, and Mrs L was called back into the hospital on the day when he sadly died.
77. We can see evidence in the medical records of psychological support and daily communications with Mrs L throughout the critical care stay. Mrs L also told us that she was in contact with her husband via telephone and video calls.
78. The BMJ published an article about COVID-19:
‘During the COVID-19 pandemic, hospitals across the UK had to restrict inpatient visitors to help prevent the spread of the virus. On 24 March 2020, Chelsea, and Westminster NHS Trust stopped allowing visitors to its wards apart from in exceptional circumstances.’
79. Our adviser said the suspension of visiting was in line with all other NHS providers and as a nurse who worked in critical care during the pandemic, this was the practice that all units were following at this time.
80. Our adviser said there is no sign from the evidence that the Trust should have allowed Mrs L to visit any sooner, based on the guidelines at the time.
81. We find the Trust acted in line with the COVID-19 guidelines at the time and have found no sign of failing.
82. We recognise it was very distressing and upsetting for Mrs L to not be able to visit her husband for most of his hospital stay while he was unwell.
83. We hope this statement provides some reassurance to Mrs L about the care and treatment her husband received.