15. 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.
16. If we see signs something went wrong, we consider whether this had a negative impact which the organisation has not yet put right.
17. We will not do a detailed investigation of a complaint if we see no signs something went wrong, or the negative impact of a mistake has already been put right.
Dairy intolerance
18. Miss A is unhappy the Trust did not do anything about her mother’s dairy intolerance until 10 September. Before this, it was giving her food and drink that contained dairy.
19. Miss A says she raised the issue with staff on an almost weekly basis. We also saw entries in the medical records from 5 and 30 July which show some staff knew about the dairy intolerance, but it was not acted on.
20. On 10 September there is an entry in the medical records after a doctor spoke to Miss A about some of her concerns. The dairy intolerance was formally recorded and Mrs N’s food and drink were adapted after this.
21. In its response to the complaint the Trust apologised for the delay in recognising Mrs N’s dairy intolerance. It explained it happened because the information did not get passed to the correct team members.
22. It also said staff should have been more curious about why Mrs N was not eating her food. It said ‘we would like to extend our apologies that the ward staff did not check to see why Mrs N was not eating her food. Whilst nurses encourage all patients to eat and drink, we acknowledge that if a patient is not eating, more probing should be completed to find out the reason’.
23. Miss A is concerned the delay in acting on her mother’s dairy intolerance caused her to lose weight and have diarrhoea which worried and upset Miss A.
24. The records show that by 10 September Mrs N only had one episode of diarrhoea and did not lose any weight. There is no sign the Trust’s mistake had a serious impact on Mrs N’s health.
25. It did, however, upset Miss A and make her worry about her mother’s health. We are sorry to hear she was left feeling this way.
26. We are reassured to see the Trust has acknowledged it got something wrong and provided an apology to Miss A in its complaint response. This is in line with our Principles, which say organisations should be open and honest. They should acknowledge when things have gone wrong and take steps to put things right.
27. We consider the Trust’s apology is enough to put this issue right and have decided we do not need to do a detailed investigation of this part of the complaint.
Pain team referral
28. Miss A says her mother suffered long term pain and was known to the pain team before this admission. She thinks the Trust should have arranged for the team to see her mother sooner than 10 September.
29. The Trust did not identify any issues with the timing of the referral to the pain team in its investigation of the complaint.
30. Our adviser explained that every doctor is trained in managing pain and a referral to the pain team should only happen when specialist input is needed.
31. The pain management standards say before someone is referred to a specialist pain team, their pain should be investigated. They should be referred to specialists if either: • no cause for the pain is found • there is no treatment that can be given, or • treatment has failed to relieve pain.
32. Mrs N had been assessed by the pain team around a month before her admission to hospital. They noted her long-term history of back pain and headaches and told the GP in a letter that a pain patch could be considered if oral pain relief was not working. The doctors looking after Mrs N in hospital had a copy of this letter and were aware of the advice.
33. Our adviser explained it was important for the doctors to understand the pattern and severity of Mrs N’s pain, and how it responded to pain relief. This can be difficult to understand as pain can be complicated if someone does not show signs of pain or say they have no pain.
34. Mrs N’s medical records show her reports of pain come and go during the admission. At times she reported no pain or had pain but would not accept pain relief, sometimes due to confusion caused by her dementia.
35. As part of the investigation into Mrs N’s pain the Trust did a brain scan in August. It also did a blood test to look for inflammation that might be affecting the brain and repeated the blood test on 8 September. During this time the Trust also changed Mrs N’s pain medication and considered a pain patch. This was not initially given as oral pain relief appeared to be working.
36. The Trust then referred Mrs N to the pain team on 10 September after a discussion with Miss A, when she felt her mother’s pain was persisting despite treatment. She was very keen for her mother to be referred.
37. Our adviser explained the Trust took appropriate steps, in line with the pain management standards, to investigate and attempt to manage Mrs N’s pain in the first instance. Considering the criteria for referral set out in the pain management standards, this needed to be done before a referral to the pain team could happen.
38. We recognise this matter was a worry for Miss A. We have seen no sign the Trust got something wrong when it did not refer Mrs N to the pain team sooner.
Bruises
39. Miss A found bruises on her mother’s arms underneath a nicotine patch on 19 October. She is concerned the staff were not aware of the bruises until she told them. She says this made her feel helpless, stressed, sad, and she worried about what else was being missed.
40. The records say that once Miss A told the staff about the bruises, they made a note of them and checked them over.
41. In its response to the complaint the Trust apologised to Miss A that staff did not notice the bruises earlier. It said this is the sort of thing that staff should pick up on and record in the notes.
42. In line with our Principles the Trust accepted it made a mistake, explained what it got wrong, and apologised to Miss A.
43. Miss A wants the Trust to make improvements to its service to prevent a mistake like this from happening again. We considered whether this would be fair in the circumstances.
44. We can see from the records there were occasions where staff tried to check Mrs N’s skin and were not able to do so. She tended to decline these checks because of her dementia.
45. We have seen no sign the missed bruises were an ongoing or repeated issue. This is not an issue resulting in permanent harm or prolonged suffering and appears to be due to a one-off oversight in nursing care.
46. We consider the Trust’s apology and explanation is enough to put things right and have decided we do not need to do a detailed investigation of this part of the complaint.
Resuscitation and ventilation decisions
47. Miss A is unhappy with the Trust’s decision to put a DNACPR in place, even when she objected to it. She is concerned it referenced ‘frailty’ as a reason for the DNACPR.
48. She also complains about the Trust’s decision that her mother would not be put on a ventilator. She says her mother was not coping with the oxygen mask because she was claustrophobic (had a fear of confined spaces) and being on a ventilator would have helped her get the oxygen she needed.
49. The records show us the Trust held a meeting on 24 November to decide what to do about Mrs N’s COVID-19 deterioration and the difficulties in giving her treatment. The Trust considered whether Mrs N would be suitable for invasive ventilation on critical care and if a DNACPR decision was needed.
50. The Trust decided it would not resuscitate or provide ventilation for Mrs N if she deteriorated as this would not alter the outcome or offer any benefit due to her poor health. It decided to continue with other treatment such as oxygen and medication and planned to use gentle sedation to support this.
51. The Trust did not identify any issues with the DNACPR or ventilation decisions in its investigation of the complaint.
52. The NICE guidance says the degree of frailty should be considered for all patients in hospital, using the Clinical Frailty Scale. This helps with decision making and critical care teams should be involved in decisions about invasive ventilation for frail people (a score of 5 or more on the scale).
53. We think the Trust acted in line with the NICE guidance when it considered Mrs N’s frailty. Our adviser considered Mrs N had a frailty score of 6. We think it was appropriate the critical care team were involved in the meeting on 24 November.
54. The NICE guidance says decisions about whether a patient should go to critical care should be based on how likely the person is to recover, bearing in mind their clinical history and how bad their illness was.
55. Our adviser explained ventilation is not guaranteed to be successful. Many people do not survive it. The ICNARC data shows that between September and December 2020, 71% of people aged over 70 who were ventilated in critical care sadly died.
56. Our adviser explained she was at high risk of death from COVID-19. A measure called the 4C mortality score is used to assess this risk. Our adviser said Mrs N’s score was 13 out of 21 which is a high risk of death from COVID-19.
57. Our adviser considered Mrs N’s circumstances and said she was unlikely to survive being on a ventilator. We think the Trust’s decision to not offer ventilation based on there being no prospects of success was appropriate and in line with the NICE guidance.
58. We understand this was a very difficult decision for Miss A to accept, particularly as she felt her mother was only not wearing the oxygen mask due to claustrophobia.
59. Our adviser says a common feature of people with dementia is that as the disease progresses, they start to refuse some of their care such as eating, washing, or accepting treatment. This is worse when someone is unwell. It would not have been clinically appropriate to ventilate Mrs N and her reluctance to wear an oxygen mask, whether through claustrophobia or dementia, would not change that.
60. The resuscitation guidance explains CPR is an invasive and traumatic medical intervention, with a relatively low survival rate. It can cause serious damage to internal organs, and if unsuccessful can lead to someone dying in an undignified and traumatic manner.
61. The resuscitation guidance says decisions about CPR are clinical decisions and should be made if there is a good reason to believe a person is going to die from an advanced or irreversible disease, and that resuscitation would not work. It says ‘if there is no realistic prospect of a successful outcome, CPR should not be offered or attempted’.
62. The resuscitation guidance says if a patient lacks the ability to be involved in a DNACPR decision, their appointed welfare attorney (power of attorney) must be told about the decision. However, the welfare attorney is unable to demand CPR if the clinical team have decided it is clinically inappropriate.
63. Our adviser explained CPR would have been clinically inappropriate in Mrs N’s circumstances. She was at a high risk of dying from COVID-19, and performing CPR to restart the heart would not reverse the COVID-19 pneumonia that was making her very unwell.
64. Although Miss A held power of attorney and did not agree with the DNACPR decision, the Trust was still able to put one in place as CPR cannot be demanded if clinicians feel it is not clinically justified.
65. We think the Trust’s decision to put a DNACPR in place because there was no prospect of a successful outcome, despite Miss A not agreeing, was in line with the guidance.
66. We have not seen any signs something went wrong when the Trust decided to not offer resuscitation or ventilation for Mrs N. We have decided not to investigate this part of the complaint. We know these were very serious concerns for Miss A, and we hope our explanation helps to address these issues for her.
Summary
67. We recognise there were challenges throughout Mrs N’s long admission to hospital, and we understand why Miss A had concerns.
68. We have decided not to investigate the complaint further because we saw no signs something went wrong for some of the issues raised, and the other issues have already been put right. While this is not the outcome Miss A had hoped for, we hope she is reassured by the explanation for our decision.