16. Mrs U complains that staff did not follow standards and guidelines when they gave Mr U IV fluids on 25 and 26 November. She says they gave her husband too much.
17. In the Trust’s complaint response to Mrs U on 4 April 2024, it said staff prescribed Mr U IV fluids on 25 November 2022 because he was showing signs of dehydration. It said Mr U’s clinical notes confirmed the fluids were appropriate according to NICE guidance. Although there was a suggestion of fluid overload, it explained staff treated this with frusemide (a diuretic which increases urine output to eliminate excess fluid) which is the recognised treatment when staff suspect fluid overload.
18. Before we decide whether we need to take further action, 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 that in this case.
19. A consultant examined Mr U on the morning of 25 November. They said Mr U had hospital acquired pneumonia, and he should continue to have antibiotics over the weekend.
20. A registrar and a junior doctor examined Mr U at 6.10pm on 25 November. They recorded they spoke to Mrs U and she was concerned about Mr U’s lack of fluids. The junior doctor explained staff had inserted a new cannula and they had prescribed a fluid regime for over the weekend.
21. The NICE guidelines (the guidelines in place at the time of Mr U’s care) cover the general principles for managing IV fluid therapy in hospital. They aim to help prescribers understand the optimal amount and composition of IV fluids to be administered and the best rate at which to give them. These guidelines say: • IV fluids should be prescribed and administered by skilled and competent healthcare professionals • IV fluid prescriptions should include the type of fluid to be administered and the rate and volume of fluid to be administered • patients should have an IV fluid management plan which should include details of the fluid and electrolyte prescription over the next 24 hours and the assessment and monitoring plan.
22. We also looked at GMP which describes what is expected of all doctors registered with the General Medical Council. It says in providing clinical care, doctors must provide effective treatments based on the best available evidence.
23. We have not been able to determine whether the registrar or the junior doctor prescribed Mr U’s IV fluids. In either case, both were suitably qualified doctors who are permitted to prescribe and administer IV fluids in line with the NICE guidelines.
24. The NICE guidelines recommend different prescriptions of fluid depending on a person’s body weight. For Mr U’s weight, they explain he should have received between 1,975ml to 2,370ml over a 24 hour period.
25. Mr U’s records show the Trust initially prescribed one litre (1000ml) of IV fluid with a running duration of 12 hours on 25 November. The chart shows staff prescribed another one litre, also with a running duration of 12 hours, on 26 November with a start time of 9.30am. This means the total prescribed fluids for Mr U over 24 hours was 2,000ml. This is in line with the amounts set out in the NICE guidelines.
26. IV fluids are administered via a volumetric pump and documented in millilitres per hour. The patient’s fluid output is recorded over the same period. This shows a net fluid intake (which will be either positive or negative).
27. The records we have seen do not include a fluid balance chart for 25 November. We would expect the Trust to complete one. We have seen staff completed a fluid balance chart each hour from 8am to 6pm on 26 November. This showed Mr U’s intake from the IV fluids, and his urine output.
28. Our adviser helped us understand these records. They explained during this time Mr U’s net fluid balance was negative which meant he was not taking on more fluid than he was passing. This means there is no indication the Trust overloaded him with fluid. Although we have not seen a fluid chart for 25 November our adviser explained the available records provide enough information to give an overall picture of Mr U’s fluid balance over 25 and 26 November.
29. The Trust carried out a chest X-ray on 26 November because Mr U’s breathing was worsening. The X-ray showed ‘widespread patchy opacification’ (where there is shadowing on the lungs where it should be clear). We can see another doctor then told Mrs U her husband had ‘infection and fluid overload’. The doctor prescribed furosemide (a diuretic which helps the body eliminate excess fluid by increasing urine production).
30. We asked our adviser why the doctor might have thought Mr U had fluid overload. They said it is not always possible to establish the exact cause of lung shadowing seen on an X-ray and it could raise the possibility of fluid on the lungs. They said the opacification was in fact more likely due to the worsening of Mr U’s pneumonia (which the Trust was already treating him).
31. A senior doctor examined Mr U on 27 November, and they noted they saw no clinical signs of fluid overload and their impression was Mr U had aspiration pneumonia. They also recorded Mr U’s legs were not swollen. Our adviser said they would expect Mr U to have had swollen legs at this point if he had been overloaded with fluid on 25 and 26 November.
32. We acknowledge the references to fluid overload caused Mrs U significant concern. Along with a deterioration in Mr U’s condition at around the same time we can understand why Mrs U might have thought the two issues were connected. We hope we can reassure Mrs U that our adviser said there is no indication Mr U was overloaded with fluid despite what staff told her. His condition deteriorated due to the progression of his pneumonia which did not respond to treatment.
33. Taking into account the guidance we have outlined and the views of our adviser, we cannot see any indication of failings in the way the Trust managed Mr U’s IV fluids on 25 and 26 November. We think the Trust acted in line with guidance and provided effective treatment based on the best available evidence. For this reason, we will not be looking at Mrs U’s complaint further.
34. We acknowledge Mrs U’s view that fluid overload caused Mr U’s death. We realise it will be of little consolation to know the Trust’s actions were consistent with guidance. We recognise how distressing these events have been for Mrs U and the ongoing impact this has on her. We hope we have gone some way towards providing an explanation about the events of 25 and 26 November to put her mind at rest.