Cardiac monitoring
16. On 5 October 2022, whilst out on a walk, Mrs K had a cardiac arrest. A passerby successfully carried out CPR and an ambulance took her to the Trust for further care and treatment.
17. Mrs G says the Trust should have placed her mother in its acute cardiac unit straight away to ensure she received the right level of monitoring and care.
18. The Trust initially reviewed Mrs K in its emergency department (ED) on 5 October 2022 at 12.21pm and the plan was to put her in its acute cardiac unit with full cardiac monitoring.
19. Despite its plan to transfer care to its acute cardiac unit, Mrs K’s care was handed over to its clinical assessment unit. The handover records at 2.22am on 6 October confirm she was placed in a side room and did not have a cardiac monitor in place as there were none available for use.
20. The records suggest Mrs K was put on a cardiac monitor from midday on 6 October whilst on the clinical assessment unit ward. However, on 7 October at 6.11am, the nursing records indicate Mrs K was ‘tearful, confused, and disorientated’ and was refusing to have the cardiac monitor connected to her.
21. Mrs K was reviewed daily by a cardiologist who did recommend a treatment plan (as detailed in the next section).
22. Although the Trust had planned to transfer Mrs K to its acute cardiac unit, there is no evidence to show why this did not happen until approximately 6pm on 8 October. The reason for transfer at this time appears to be due to her fall and further clinical decline, not because a bed had become available.
23. ERC and ESICM ‘Post-resuscitation care’ guidance emphasises the importance of continuous monitoring of patients after a cardiac arrest. This is to detect and manage complications such as arrhythmias (problems in the rate or rhythm of the heartbeat) and changes in blood pressure. Following an out-of-hospital cardiac arrest, it recommends transport to a recognised centre of care, such as a cardiac arrest centre, for appropriate specialist treatment.
24. As Mrs K had a cardiac arrest, in line with the above guidance, the Trust should have continuously monitored her heart rate and rhythm and admitted her to a specialist cardiac ward for treatment.
25. Mrs K was not transferred to the specialist cardiac unit until three days after her admission following her clinical decline. Mrs K’s heart was also not continuously monitored, due to monitors not being available in the clinical assessment unit, and then because of the issues with Mrs K not wanting the monitor connected.
26. This is not in line with the ERC and ESICM guidance and we consider this to be a failing. We will address the impact of this later in the report.
Risk assessment for acute coronary syndrome
27. ESC ‘Management of acute coronary syndromes in patients presenting NSTEMI’ guidance recommends using a Global Registry of Acute Coronary Events (GRACE) as a validated risk assessment score to determine the level of monitoring and urgency of required intervention. It considers this score-based risk assessment to be superior to subjective physician assessment.
28. Further NICE ‘acute coronary syndrome’ guidance says most risk scoring systems currently predict the likelihood of mortality or ischaemic cardiovascular events at various times after a patient's admission to hospital with acute coronary syndrome. Timely interventions have shown to reduce these adverse outcomes.
29. The Trust’s ‘Early Management of unstable angina and NSTEMI’ policy says to use the validated Thrombolysis In Myocardial Infarction (TIMI – a type of heart attack) risk score for its patients. This policy shows how to score patients based on a number of factors, such as a patient’s history and their presenting issues. Low risk scores are between 0-2, Intermediate risk is 3-4, and High Risk is 5-7.
30. We can see from the records that the Trust’s plan in the ED was to follow its acute coronary syndrome protocol. The Trust says its cardiology team reviewed Mrs K daily. It said this gave them a regular assessment of her needs and informed on the timeliness of important investigations. It says, although there was no risk score documented in her records, her acute coronary syndrome risk assessment was ongoing.
31. The Trust performed blood tests and an ECG in the ED. These showed she had a very high troponin (a protein found in heart muscle cells – high levels indicate heart damage) levels, and an abnormal ECG. Therefore, our cardiology adviser said in light of these test results and as Mrs K had an out of hospital cardiac arrest, a formal risk assessment should have been carried out, including a risk score.
32. Our cardiology adviser has calculated the risk score using the GRACE score based on the admission records as 140. This puts Mrs K in the highest risk category. This score means she required early interventions.
33. The Trust did not use a risk assessment score in line with the above guidance, and we consider this to be a failing. We will address the impact of this later in the report.
Antibiotics
34. Mrs G says Trust staff told her that her mother should have been given antibiotics on admission. She says this has left her wondering whether things would have turned out differently had antibiotics been given earlier.
35. The Trust says its cardiology team assessed Mrs K following her admission and there was no indication she required antibiotics before 8 October.
36. Our cardiology adviser says Mrs K was admitted following an out of hospital cardiac arrest where she lost consciousness and CPR was performed. Therefore, she was at an increased risk of chest infection from aspiration pneumonia (a lung infection that happens when food, liquid, saliva, or vomit is inhaled into the lungs instead of being swallowed) or pre-existing pneumonia. Both of which could cause further cardiac or respiratory arrest.
37. Blood tests results show a C reactive protein (CRP) level. The CRP test shows the levels of inflammation and infection in the body. The blood test results on Mrs K’s admission shows a CRP result less than 4mg/l. Our cardiology adviser says this would be considered normal and would not necessarily indicate an infection.
38. The ERC and ESICM ‘Post-resuscitation care’ guidelines recommend considering antibiotic use for patients with clear suspicious infiltrates (abnormalities) on chest X-rays or scans.
39. The CT pulmonary angiogram, which was done on 5 October, showed signs of atelectasis (collapse of the lung or part of) /consolidation (filling of the lung’s air spaces with fluid, pus, or other material) as well as lower lobe changes consistent with inflammatory disease. Our cardiology adviser said these are signs of infection.
40. Blood tests at 8.43am on 6 October showed that Mrs K’s CRP levels had risen to 27mg/l. Our cardiology adviser said anything above 10mg/l would not be considered as normal.
41. Our cardiology adviser says at this stage Mrs K had accumulating signs of infection. Therefore, we conclude that in line with the ERC and ESICM guidelines, and the developing clinical picture, Mrs K should have been given antibiotics by the morning of 6 October at the latest.
42. On 8 October at 9.49am, the records indicate the plan was for intravenous (IV) antibiotics to be given to Mrs K for pneumonia. However, the records indicate antibiotics were not started until 4.54pm. This means that there was around a 56-hour delay in administering antibiotics to Mrs K, which we consider to be a failing.
43. We will address the impact of this failing later in the report.
Perform a coronary angiography
44. Coronary angiography is a specialised X-ray test to find out detailed information about the heart (coronary) arteries. It is mainly used when a patient has angina or had a heart attack, to assess which if any of the arteries are blocked, and how severely the arteries are blocked. This helps the doctor to decide on what treatment is needed.
45. NICE ‘acute coronary syndrome’ guidance says to consider coronary angiography within 72 hours of first admission for people with unstable angina or NSTEMI who have an intermediate or higher risk of adverse cardiovascular events.
46. The Trust says it had planned to perform a coronary angiography during Mrs K’s admission. It says there was no indication the coronary angiography needed to be performed immediately.
47. It says Mrs K’s admission was complicated by other comorbidities (the presence of two or more medical conditions) so performing an invasive cardiac procedure, such as a coronary angiography, would have increased the risk for her and could have compromised the potential benefits. Mrs G says Trust staff told her that her mother would be considered for a pacemaker when she became strong enough.
48. Despite the Trust’s plan to carry out a coronary angiography and angiogram, along with the fitting of a pacemaker, Mrs K sadly died on 10 October without these taking place.
49. Our cardiology adviser says the Trust should have performed the coronary angiography within at least 72-hours of Mrs K’s admission. She presented as high risk on admission, based on the risk score above, which indicated the need for quick intervention. This should have been taken into account when deciding how quickly to do it. Our adviser said an earlier angiography, within 24-hours would have been more appropriate. The delay meant Mrs K’s health continued to get worse as her infection developed and made it difficult for the Trust to then safely carry out the angiography.
50. We are of the view the Trust delayed caring for Mrs K in its specialist cardiac unit and missed opportunities to give timelier care and treatment, such as high-risk acute coronary syndrome scoring and earlier administration of antibiotics. Had these happened, Mrs K may have been stable enough to undergo the procedure. Therefore, we have found the Trust failed to carry out a coronary angiography within 72 hours of Mrs K’s admission in line with NICE guidance. We will address the impact of this later in the report.
Clinical assessment unit nursing monitoring
51. Mrs G says the nursing staff failed to adequately monitor her mother’s condition whilst on the clinical assessment unit. She says she was upset to learn the Trust had placed her mother in a side room, especially given her dementia diagnosis. She also complains that the lack of monitoring led to her mother having an unwitnessed fall, which she believes would not have happened if she had been monitored appropriately.
52. The Trust accepts a side room was not the most appropriate location because of Mrs K’s dementia and the need for close monitoring. It confirmed the door was left open and nursing staff checked on her frequently.
53. Mrs G says her mother had episodes of delirium and was unsteady on her feet. Despite this, nursing staff did not help and support her mother to mobilise or to get to the toilet.
54. NMC ‘Future nurse: standards of proficiency for registered nurses’ says to accurately process all information gathered during the assessment process to identify the individual patients’ needs. Using this information, ensure individualised nursing care, and any support required, is put in place to meet those needs.
55. NICE ‘Falls in older people: assessing risk and prevention’ guidance says to undertake a comprehensive assessment to identify a person's risk factors for falling and identify whether the risk factors can be treated, improved, or managed.
56. The Trust’s nursing staff assessed Mrs K on admission and considered her to be independent with her eating and drinking meaning she was low risk of malnutrition and did not need any support. The records also indicate nursing staff assessed Mrs K’s pain levels regularly and assessed her skin to ensure it appropriately considered her risk of developing pressure ulcers.
57. The records clearly show Mrs K was confused and did not want to be placed in a side room. The falls risk assessment concluded she was at risk of falling, had an ‘unsteady gait’ and anxiety over falling, and she was assessed as needing the assistance of one for personal hygiene and toileting.
58. There is evidence to show increased hourly rounding was initially in place during the night of 6 October. This meant nurses were checking on her every hour to ensure she was not in pain and was comfortable, to support with bathroom visits, and to ensure access to any items needed.
59. Our nursing adviser says this was an appropriate level of care because the assessment had concluded Mrs K needed toileting assistance and because she was not always in sight given she was in a side room.
60. There is evidence to show the Trust initially acted in line with the NMC standards and NICE guidance by conducting appropriate assessments and ensuring an individual plan was in place to support Mrs K hourly.
61. Unfortunately, there are no records to show that this continued after midday on 6 October. This meant the Trust were not checking on Mrs K to see if she needed any assistance. Therefore, we have found Trust nursing staff did not fully meet her individual needs in line with the NMC standards.
62. Although Mrs K spent some time on the main ward, she was transferred back to the side room at some point prior to her ‘unwitnessed fall’ on 8 October.
63. The records clearly show Mrs K was confused and did not want to be put in a side room. Our nursing adviser said these should have been identified as risk factors. Being placed in a side room made it difficult for staff to support her and help her to mobilise.
64. Despite the Trust undertaking a falls risk assessment, we are of the view it did not act in line with NICE guidance to closely monitor Mrs K to manage or reduce her risk of falling.
65. We will address the impact of the clinical assessment unit nursing monitoring later in the report.
Post-fall care
66. Mrs G says the fall caused her mother ‘catastrophic’ injuries to her face. She says this was very distressing to see and further compounded her feelings that her mother was not being sufficiently monitored and cared for.
67. NICE ‘Quality statement 4: Checks for injury after an inpatient fall’ says when a person falls, it is important that they are assessed and examined promptly to see if they are injured. This includes neurological observations where a head injury has occurred.
68. Further, the NHSE ‘Report a patient safety event’ strategy says healthcare staff are encouraged where possible to record all patient safety incidents on their organisation’s local risk management systems (LRMS). These reports will then be routinely uploaded to NHSE systems to support national learning.
69. Following Mrs K’s fall, the records indicate the Trust promptly carried out neurological and blood tests, a CT scan of her head, a chest X-ray, and gave her the oxygen support she required in line with the NICE quality statement.
70. The records show Trust staff logged an incident report the same day with details about Mrs K’s fall and the post-fall actions taken. This included updating Mrs K’s fall assessment in line with the NHSE strategy.
71. We acknowledge the distress it caused Mrs G to see her mother’s subsequent injuries. We hope it provides her with some reassurance that we have found the Trust adhered to the NICE guidance by ensuring her mother was promptly examined and they carried out further tests and investigations to ensure any injuries were treated. We have also found the Trust acted in line with the NHSE strategy following her fall by logging the incident.
Chest X-ray
72. The Trust carried out a chest X-ray on Mrs K following her fall on 8 October. However, there is no documentation to suggest the Trust reviewed this at the time.
73. GMC ‘Good Medical Practice’ guidance says doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary.
74. Following Mrs K’s fall, her condition further declined, and her oxygen saturation levels were decreasing. The Trust put her on 30% oxygen via venturi (a non-invasive mask) and requested a chest X-ray to see if she had a chest infection.
75. The Trust’s website says in-patients usually receive most scan results the same day. Given the need for the X-ray, our cardiology adviser says it should have been interpreted the same day alongside the other test results to make a decision on Mrs K’s management.
76. The records suggest the chest X-ray report was not available until 13 October, which was three days after Mrs K’s death, and five days after it was performed.
77. We have found the Trust failed to act in line with the GMC guidance as it did not promptly report and interpret the chest X-ray done on 8 October. This meant that the Trust did not have the full information about her clinical picture. We will address the impact of this failing later in the report.
Arterial blood gas (ABG) test
78. Mrs G says the Trust failed to carry out a timely ABG test. This meant her mother’s condition continued to deteriorate without the correct care and treatment being given to her. She also says, had the Trust identified Mrs K as being acidotic earlier, it could have referred her to the palliative care team for end-of-life care. This would have made her more comfortable and would have allowed her to die in a more dignified manner and would not have been as traumatic as it was for her and the family.
79. BTS ‘Oxygen use in adults in healthcare and emergency settings’ guidance says arterial blood gases should be checked if oxygen saturation falls by more than three percentage points. This should be done as soon as possible to check whether there is carbon dioxide retention with risk of respiratory acidosis. The result of the test informs of the level of carbon dioxide present. In turn, this indicates the treatment needed to ensure the right oxygen saturation level is achieved.
80. The records show initially, on 9 October at 7.30am, Mrs K required 35% oxygen. This later increased to 40% when her oxygen saturation levels decreased, and by 10am she was receiving 60% oxygen via a mask. Mrs K’s oxygen saturation levels had decreased from 95% to 88% during this time, so the Trust increased her oxygen and the plan was for an ABG to be done.
81. As Mrs K’s oxygen saturation fell by more than three percent between 7.30am and 10am, in line with the BTS guidance, the Trust should have checked her ABG as soon as possible after 10am. Despite the Trust’s plan to carry out an ABG at 10am on 9 October, it was not done until 2.10am on 10 October. This means there was a 16-hour delay in carrying out the ABG test. We are of the view this was not in line with BTS guidance. We will address the impact of this later in the report.
Impact
82. Mrs K died on 10 October from a heart attack. From reviewing the records, it is suspected that she developed pulmonary oedema, heart failure and pneumonia as a complication of her original cardiac arrest. This led to her subsequent cardiac arrest and death.
83. We are of the view the Trust should have transferred Mrs K’s care to its specialist acute cardiac unit on her admission because she had suffered an out-of-hospital cardiac arrest. Our cardiology adviser says, had this happened, she would have received continuous cardiac monitoring, had access to the right level of medical care, and received 1:1 ratio of nursing care.
84. Unfortunately, this did not happen, so she was cared for by clinical assessment unit nursing staff who did not give her adequate support to meet her needs. This likely set Mrs K’s care for the rest of her admission and led to the Trust missing a number of opportunities to give her better, and timelier, care and treatment.
85. On admission, Mrs K should have been risk assessed and given a TIMI risk score. The Trust’s lack of scoring meant Mrs K’s assessments were subjective and based on an individual’s personal opinions. Her treatment was not considered objectively using the validated risk score, TIMI. These objective clinical assessment tools are more evidence based and more robust in acute coronary syndrome management decision making.
86. Our cardiology adviser says, Mrs K’s high-risk features for acute coronary syndrome included the documented ischemic ECG changes. This meant Mrs K had insufficient blood flow which affected her oxygen levels. The echocardiogram (ultrasound of the heart) showed she also had an impaired left chamber of the heart. The CT pulmonary angiogram showed cardiomegaly (an enlarged heart) and reported features of heart failure and pleural effusion (accumulation of fluid in the area between the lungs and the chest). She also had raised natriuretic peptide (NT-ProBNP -an enzyme which increases with heart failure) test results.
87. Had the Trust objectively scored Mrs K based on these results, it would have recognised her high-risk status earlier and the need for timely action. Unfortunately, this was not evidenced. This meant the Trust continued to care for Mrs K on its clinical assessment ward.
88. As the Trust was not caring for Mrs K in its specialist acute cardiac unit and had not scored her as high-risk, this likely informed the Trust’s view she did not need an ‘immediate’ coronary angiography. This meant it was not done before her condition further deteriorated.
89. We know the Trust wanted to carry out a coronary angiography to inform its treatment plan of fitting Mrs K with a pacemaker. Whilst we consider the Trust should have done a coronary angiography before Mrs K deteriorated, we cannot say that it would have been able to perform the operation to fit a pacemaker thereafter. This is because Mrs K deteriorated within a few days after admission, and it is possible that she would have been too unwell to undergo this operation by the time it had been scheduled.
90. ECS and NICE guidance recommendations show procedures such as coronary angiography and pacemaker, along with early management of acute coronary syndrome, reduces in-hospital mortality for these patients. We cannot say, even on balance, this would have meant Mrs K would have survived. This is because our cardiology adviser says mortality rate for out of hospital cardiac arrest is very high hence the survival outcome is generally poor. Nevertheless, we are of the view the Trust missed early opportunities which may have reduced Mrs K’s risk of death.
91. In relation to the delay in antibiotics our cardiology adviser said because high risk acute coronary syndrome has a high hospital mortality it would have been difficult to predict if earlier antibiotics would have made a difference to the outcome as Mrs K had other comorbidities such as heart failure, all which contributed to her deterioration and death.
92. However, the NHS webpage for pneumonia does state that confusion is a common symptom for older patients. As this went untreated for around 56 hours, it is likely that this led to Mrs K becoming more confused, which may have contributed to her subsequent fall on 8 October.
93. Having considered all available evidence, we cannot say, even on the balance of probabilities, that Mrs K’s fall, and subsequent injuries, were preventable. This is because, despite increased monitoring checks, there would always be a period of time when Mrs K would be alone. That said, had the Trust appropriately monitored Mrs K in its specialist acute cardiac unit instead of in a side room and given her timelier antibiotics, this could have helped to manage and reduce her risk of falling.
94. Our cardiology adviser says Mrs K’s clinical condition appeared to deteriorate rapidly after the fall, although this was more likely due to her lung and heart status following her heart attack and chest infection as shown by deteriorating oxygen level and blood pressure, rather than the fall itself.
95. Following the fall, the Trust carried out a chest X-ray. This X-ray showed Mrs K had pulmonary oedema. Due to the fact the Trust did not review this, it did not adjust Mrs K’s treatment according to the findings.
96. NICE ‘Acute heart failure: diagnosis and management’ guidance says not to routinely use non-invasive ventilation (such as through a face or nasal mask) in people with acute heart failure and cardiogenic pulmonary oedema.
97. Our cardiology adviser says it appears the Trust continued to treat Mrs K for chest infection as the cause of her respiratory failure. This is because oxygen and IV antibiotics continued. Had the chest X-ray been reported on the day, along with the other known cardiac conditions and test results, the Trust should have treated her for pulmonary oedema. Our cardiology adviser said this was likely to be the main cause of her respiratory failure. This caused hypoxia (low levels of oxygen in the body’s tissues) with subsequent hospital acquired pneumonia.
98. Our cardiology adviser says the treatment for pulmonary oedema includes giving medication (diuretics) to remove excessive fluid from the lungs. On 8 October, Mrs K was given intravenous fluid at a rate of 83.3 ml/hour and was on high flow oxygen at seven litres. As above, oxygen therapy is not recommended for patients with pulmonary oedema, and our cardiology adviser says this, and the fluids, could have made the unrecognised pulmonary oedema worse.
99. Finally, our cardiology adviser says, as Mrs K was on high flow oxygen, the ABG should have been done straight away to find out the level of carbon dioxide present. This helps to determine the next step in the escalation process in respiratory support, such as the type of non-invasive ventilation, or whether invasive ventilation was more appropriate. This would also have given an indication that Mrs K was deteriorating and that her prognosis was poor.
100. Mrs K’s oxygen saturation levels continued to decrease throughout the day despite being on high levels of oxygen. Had the Trust done an ABG and the acidotic results been known earlier, it should have assessed the type of ventilation support Mrs K needed. Mrs G could have also been informed about her mother’s significant deterioration, that her prognosis was poor, and she was nearing end-of-life.
101. The Trust admits it delayed carrying out the ABG test on 9 October and accepts the results may have led to an earlier referral to its Supportive Palliative Care Team. This team department gives specialist care and information to people facing serious illness and life limiting conditions. It can ensure end-of-life patients are comfortable and pain-free and gives support to family members.
102. Given the short time frame between 10am on 9 October to Mrs K’s death around 3am on 10 October, we find that a referral to the Trust’s Palliative Support Team may not have resulted in Mrs K and Mrs G being seen. That said, had the ABG been done in line with BTS guidance, the results would have informed of the treatment required to ensure she was made comfortable in those final hours. This could also have prevented Mrs G having to witness her mother’s suffering and the trauma that was caused as a result.
103. Given the failings and the missed opportunities, we have concluded the injustice for Mrs G is she is left with uncertainty and distress about whether her mother’s outcome could have been better had these failings not happened.
104. We are very sorry to learn Mrs K did not get the standard of care she deserved, and we acknowledge the impact this had on her and Mrs G. We recognise the significant distress Mrs G went through watching her mother deteriorate so quickly. We understand she had to witness her mother suffer in pain, some of which could have been avoided. We appreciate the traumatic circumstances leading up to her mother’s death has made it more difficult for Mrs G to find closure. We hope the recommendations we have made offers Mrs G some reassurance that no one else will have the same experience.