15. The relevant guidance which applies here is the Royal College of Physicians (RCP) National Early Warning Score (NEWS2) guidance. The guidance outlines the recommended response according to the patient’s NEWS score. Under this guidance, a patient is assessed and given a score in relation to their physiological measurements. These can also be referred to as clinical observations and consist of;
• Respiration rate • Oxygen Saturation • Systolic blood pressure • Pulse rate • Level of consciousness or new confusion • Temperature
16. The above NEWS guidance has been incorporated by the Trust into its ‘Management of Acutely Deteriorating Adult Inpatients’ policy.
17. The nursing records document that staff carried out clinical observations at 9.15pm on 1 June 2022. A NEWS of 0 was recorded. The notes also state Mr X’s airway was clear and he was displaying no breathing difficulties. He was awake, alert and responsive, which indicates that the nurse had undertaken some form of interaction with him.
18. In accordance with the guidance a NEWS of 0 meant that Mr X required his observations to be done a minimum of 12 hourly. Therefore, if Mr X had not become unwell, then he would not have required his observations checking again until the morning. However, when staff noticed Mr X was unwell on 2 June with coughing and vomiting, he should have been monitored at least hourly in accordance with the NEWS2 guidance.
19. The next nursing note is written in retrospect on 2 June at 7.45am. Our nursing adviser has been unable to accurately detail the times that the actions recorded occurred. The Trust has told us that the retrospective note, nurse’s statement and the information within the investigation report is the only evidence available.
20. The clinical observations chart on the EPR (electronic patient record) only shows the set of clinical observations done at 9.15pm. However, within the retrospective note, the nurse has indicated observations were done between 4am to the time of Mr X’s cardiac arrest which was after 7am. These have been included in the Trust’s investigation report.
21. The nurse’s retrospective entry in the records states that the nurse noticed Mr X was coughing, therefore sat him up and assisted him with hygiene needs. It states that his clinical observations were done. However, the record does not specify the time and we cannot find it in Mr X’s electronic patient record (EPR). The Trust’s investigation report indicates that this was at 4am.
22. The nurse has not recorded a NEWS in the documentation. Our nursing adviser said in accordance with the above guidance Mr X would have been scoring a NEWS 5. The Trust has said this should have prompted a referral to CCOT/iMobile in accordance with its policy. Its policy states,
23. “A NEWS2 score of 5-6 should be immediately escalated to the nurse in charge, lead clinical team and referred to CCOT/iMobile. The patient should be assessed to decide the response and treatment required”. This did not happen.
24. However, because of Mr X’s vomiting and other symptoms the nurse did contact the on-call medical team. There is some conflicting evidence as to when the doctor attended to assess Mr X. The Trust investigation report says the call was made at 4.30pm. The doctor’s statement to the coroner indicates it was her belief she was bleeped after 5am and she attended shortly after that. The doctor started her note in the electronic records at 5.38am and completed it at 5.51am. The advice from our acute medicine adviser is that taking into account those timings the doctor is likely to have arrived around 05:23am to assess Mr X.
25. While the Trust’s own escalation policy indicates the patient should be escalated to the nurse in charge, the lead clinical team and referred to CCOT/iMobile, there is no timeframe stated for when a review should occur. Our acute medicine adviser said the RCP NEWS2 information does not give a specific timeframe. However, the NICE guideline ‘Acutely ill adults in hospital: recognising and responding to deterioration’ does provide some more information, but no specific timeframes. A score of 5 would be a ‘medium score group’ score, which stipulates “Urgent call to team with primary medical responsibility for the patient”, but no timeframe.
26. Overall based on the interpretation of ‘urgent’ and their experience, our acute medicine adviser has suggested an appropriate timeframe for review would have been within an hour. If the observations were done at 4am and the doctor arrived at around 05:23 (as described above), then this is just over that timeframe. However, our acute medicine adviser said given it was the middle of the night with much lower doctor staffing, this would not be unreasonable particularly as there is no defined timescale.
27. The doctor’s notes indicate she had diagnosed aspiration. Our acute medicine adviser said the doctor who attended Mr X had put an appropriate plan for oxygen (to target saturations 88-92%), start an anti-sickness medication, start amoxicillin and metronidazole (antibiotics that would cover aspiration pneumonia), to take blood tests, request a chest X-ray and prescribe fluids.
28. However, the doctor had also noted Mr X’s abdomen to be distended and he was vomiting, but there was little indication of her thoughts about what the underlying cause of this was. Our acute medicine adviser said a patient with a distended abdomen and vomiting may have a lot of fluid in their stomach that they are vomiting (sometimes as the stomach contents are not moving down into the intestines). In this situation, a Ryles tube should be considered. This is a tube inserted through the nose and down into the stomach to help drain this fluid away to relieve vomiting and reduce (but not eliminate) the risk of aspirating (inhaling) the vomit. Our acute medicine adviser said this should have been considered here.
29. We further note that the doctor did not refer Mr X to the CCOT/iMobile team at that point. She said in her statement to the coroner that she had relatively stabilised Mr X and that his heart rate would decrease with fluids and oxygen. Our acute medicine adviser said that as Mr X was for cardiopulmonary resuscitation and had a NEWS score of 5, a referral to the CCOT/iMobile team should have been made. This may have also prompted consideration of a Ryles tube insertion which may have made Mr X more comfortable. This did not happen.
30. The Trust report states that the nurse rechecked Mr X’s observations at 5am. However, these same observations are also referred to in the Trust’s section of the report relating to the time 4am. It is not clear at what time these observations were actually taken. The nurse’s retrospective entry only relates to these figures once so we can presume that they have been duplicated in the report. There is no record in the nursing notes or observation charts to confirm the timing of these observations. The Trust investigation report also says it is uncertain when these set of observations were taken. It also said there was no respiration rate and temperature recorded which meant there was not a full set of observations to calculate a NEWS and trigger escalation.
31. Our nursing adviser said the above observations would have scored a NEWS 5. In accordance with Trust policy this again should have led to escalation to the nurse in charge, lead clinical team and referral to CCOT/iMobile. However, the nurse said Mr X was already attended to by the on-call doctor who informed the nurse Mr X was stable and to continue monitoring his vital signs. We have found a referral should have been made in line with the Trust’s policy. This did not happen.
32. The Trust’s investigation report states that following her assessment the on-call doctor told the nurse to continue to monitor Mr X’s vital signs. However, the Trust’s investigation report indicates that at 6am the nurse administered IV fluids and anti-sickness medication. There is no reference in the report to indicate Mr X had his observations checked at that time. There also does not appear to be any record in the nurse’s retrospective entry to suggest she had taken any observations at 6am. Mr X had previously scored NEWS 5 and in accordance with guidance/policy observations should be done at least hourly. The last recorded observations appear to have been done at 5am and we have found the lack of evidence of observations at this time suggests it was not done in line with the guidance/policy.
33. Ms X believes the ward was understaffed on the 1 and 2 June and that there were not sufficient staff to monitor her father. She says she was told by staff that had been moved to other wards to cover short staffing and a nurse was missing for an hour. She believes this affected the monitoring of her father.
34. The Trust has provided a copy of the staffing rota for the 1 and 2 June. The rota indicates that there were 3 registered nurses and 4 health care assistants on the ward, during the night shift when Mr X became unwell. This reflects what was said in the Trust’s investigation.
35. Our nursing adviser said Mr X was nursed in a cohorted bay, this is a bay which usually requires continuous supervision due to the patients being high risk of falls or being unable to keep themselves safe. However, if the staffing was low due to staff being moved to other wards, there may not have been enough staff to provide continuous supervision, meaning that safe nursing care could not be provided. The NICE guidance regarding safe staffing states,
“1.1.11 – Action to respond to nursing staff deficits on a ward should not compromise staff nursing on other wards.”
36. The Trust said there was adequate staff on the ward and they had increased this with an additional healthcare assistant due to the high dependency on the ward. We are unable to conclude if the lack of monitoring was due to a lack of staff during that period. However, we have found there is a lack of evidence that the nurse carried out observations in line with NEWS2.
37. At 7am the investigation report states the nurse re-checked Mr X’s observations. This would have triggered a NEWS 7. The Trust said in its response the nurse reported the observations to the nurse in charge, and they called CCOT/iMobile to review. However, the Trust advised that the CCOT/iMobile team have no record of any call until 7.25am when the cardiac arrest call was made. The indication is that the referral to the CCOT/iMobile team was not made in line with the NEWs guidance/policy.
38. We have found failings on the part of the Trust in the escalation of Mr X’s care, monitoring his vital signs and the use of a Ryles tube. Ms X believes her father died sooner than he needed to. We have considered the impact of these failings.
39. Our acute medicine adviser said Mr X was continuing to vomit despite anti-sickness medication. His deteriorating observations (mainly his oxygen saturations) would have been indicative of ongoing aspiration (inhalation of vomit).
40. Our acute medicine adviser said that unfortunately, from the point Mr X started vomiting and inhaled his vomit, his death seemed inevitable. There was an opportunity missed to consider a Ryles tube insertion which could have helped reduce the chance of further aspiration, but they did not consider this would have made a difference to Mr X’s outcome.
41. In the circumstances, we have found there were failings in the escalation of Mr X’s care, monitoring his vital signs and the use of a Ryles tube. However, taking into account the advice from our acute medicine adviser, it is unlikely that Mr X’s sad outcome could have been avoided. However, it will be a source of significant upset to Ms X that her father’s care was suboptimal and we do not underestimate that.
42. The Trust has acknowledged in its report that staff,
• had not followed the Trust’s NEWS escalation policy, • had not completed documentation of full vital signs • had not recognised and responded to a deteriorating patient.
43. The Trust has put in place appropriate actions to address these issues including staff training, quarterly audits and staff safety huddles.
44. We welcome the improvements made by the Trust. However, the Trust has not fully apologised for the above failings in care and recognised the impact on Ms X. Therefore, we have made recommendations below to provide a personal remedy to Ms X. We have also asked the Trust to provide Ms X with evidence to reassure her that the actions it planned have been fully implemented.