Northern Care Alliance NHS Foundation Trust

2. Mr E complains that between 16 August and 16 September 2019 the Trust incorrectly used a nasogastric (NG) tube on his wife. An NG tube is used to carry food and medicine to the stomach when a person has difficulty swallowing or eating. Mr E also complains the Trust would not give Mrs E thrombolysis (treatment used to remove blood clots) after she had a stroke.

3. He says the incorrect use of the NG tube caused Mrs E’s pneumonia. Mr E says his wife’s death was preventable.

4. Mr E wants an independent investigation to get answers to his concerns.

5. The Trust admitted Mrs E in August 2019 after she had a stroke. Three days later the Trust transferred her to a ward in another hospital, with an NG tube in place.

6. Almost a week later, the Trust suggested removing the NG tube. It removed the tube in early September and noted Mrs E had pneumonia.

7. A day later, the Trust’s palliative care consultant recommended moving Mrs E on to end of life care as she was unlikely to get better.

8. Mrs E sadly died later that month.

14. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something went wrong.

Thrombolysis

15. Mr E believes the Trust should have explored the use of thrombolysis to save his wife’s life. Mr E wants to know whether this treatment could have helped.

16. The Trust says it decided not to do thrombolysis because of the risks associated with bleeding. The Trust’s stroke consultant predicted Mrs E’s long-term outcome was poor and considering her frailty they thought thrombolysis was not appropriate.

17. NICE guidance says bleeding complications are the main risks associated with thrombolysis. It says the timing of administration is important when deciding how much it would benefit a patient and treatment should be given as soon as possible.

18. The records show that when Mrs E arrived at the Trust it completed the National Institutes of Health Stroke Scale (NIHSS) tool. This tool measures the amount of damage a stroke has caused and helps with treatment planning. Mrs E scored 28 on this scale.

19. Our adviser said Mrs E’s score suggested a large volume stroke. They said Mrs E would have been at high risk of bleeding and the chances of thrombolysis working in large strokes is lower. Our adviser said it is likely the risks were more than the benefits, and the decision not to give this treatment was reasonable.

20. We appreciate it is difficult for Mr E not knowing how things may have been different if his wife had the treatment. We can see the Trust acted in line with guidance in considering Mrs E for thrombolysis at the earliest opportunity. It also considered the risks. The evidence we have seen suggests it was not in Mrs E’s best interest to carry out thrombolysis. We have not seen a failing in this part of the Trust’s care.

NG tube and link to pneumonia

21. Mr E believes the Trust’s inappropriate use of an NG tube led to pneumonia. He says the tube came out at least nine times. Trust staff told him Mrs E pulled the tube out herself and other times it came out during the night or while it was being changed.

22. Mr E says the tube coming out meant Mrs E had little chance of recovery as she was missing out on hydration and medication. He also says the ulcer caused by the tube allowed bacteria to enter which led to Mrs E’s pneumonia.

23. The Trust says pneumonia is very common after a stroke as well as tubes coming out of place. In its complaint response the Trust noted the times the tube came out of place:

• 19 August – removed due to being blocked • 23 August – pulled out by patient • 26 August – became dislodged during personal care • 31 August – removed due to extensive vomiting • 4 September – removed at doctor’s request.

24. The Trust accept poor placement of the tube caused Mrs E to develop a pressure ulcer (sore).

25. NHS guidance on this says, ‘NG tubes are usually secured to the skin around the nostrils with adhesive tape and may be removed by a patient who is confused or accidentally dislodged during nursing care. Some patients may require repeated insertion of new NG tubes.’

26. It says there are two tests to check a tube has been positioned properly. One is using pH strips which measures the acidity of a substance and the other is using an X-ray. It also says an NG tube can cause pneumonia when it is misplaced into the lungs.

27. We can see from the records, the Trust followed the above guidelines on checking the position of the NG tube regularly using NG checklists.

28. Our adviser checked Mrs E’s records and said there was no evidence to suggest the Trust’s use of the NG tube was wrong and led to pneumonia.

29. We understand Mr E’s concern about the pressure ulcer Mrs E developed. We have not seen any evidence to suggest this went on to cause her pneumonia. We could only link the NG tube as a cause for pneumonia if it had been placed in her lungs.

30. We are pleased to see the Trust apologised for Mrs E developing a pressure ulcer and it has improved its service by updating its NG tube checklist to add nasal skin check. We appreciate this does not change Mr and Mrs E’s experience. We have not seen evidence of a failing with this part of the complaint.

31. We are not taking any further action but we thank Mr E for bringing his complaint to us.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr E’s complaint about Northern Care Alliance NHS Foundation Trust (the Trust). We have seen no sign that anything went seriously wrong. This decision does not take away from the sad death of Mrs E.