15. 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 happened with what should have happened. If we see signs the organisation got something wrong, we then consider if what happened fell so far short it amounts to a failing.
16. If we see a possible failing, we next consider what (if any) impact this had. If the failing had a negative impact, we consider what action the organisation has already taken to put things right. If we think it has done enough, we are unlikely to consider the complaint further.
Issue 1 – The Trust’s decision to move Mr P to a general ward
17. Mrs F complains about the Trust’s decision to transfer Mr P from the ICU to a general ward on 13 December. She is concerned he would not have suffered a cardiac arrest had he remained on the ICU where staff would have monitored him more closely. The Trust says Mr P was well enough to be on a general ward.
18. On arrival in A&E, Mr P’s oxygen levels were in the 70s on 15 litres of oxygen per minute or ‘15 L/min’ (the target for acutely ill patients with COPD is usually 88-92%). This increased to normal levels on bag mask ventilation (where a bag-valve-mask device is used to help someone breathe).
19. However, tests showed the levels of carbon dioxide in Mr P’s blood were very high. This indicates his body was failing to exhale enough carbon dioxide which a known risk in people with COPD. The Trust inserted a breathing tube and transferred him to the ICU. It did this to ensure safe ventilation and protect his airway (stop foreign substances from entering the lungs).
20. The Trust also did a head CT (a scan combining X-rays to create more detailed images of the inside of the body). The CT showed evidence of a stroke though it was not clear if this was new. Mr P had suffered a stroke earlier in the year and the Trust had no previous scans for comparison at that stage. Mr P went on to have seizures while in the ICU which can occur following a stroke.
21. The Trust removed Mr P’s breathing tube on 13 December and doctors noted he could be transferred to a general ward the following day unless there was any change in his condition. This decision was then confirmed following a ward round on 14 December after Mr P had a stable night.
22. At the time of his transfer to a general ward, Mr P’s blood pressure and heart rate were normal, and his oxygen level was 91% on 2 L/min of oxygen. The notes also say Mr P was alert, not confused, passing urine well and his blood tests showed no serious issues.
23. Our adviser explained decisions about when a patient is ready to be discharged from the ICU are made on a case-by-case basis. They are based on consultant ward rounds that take place twice a day. However, discharge generally happens once a patient no longer needs treatment only available in an ICU.
24. The ICS statement sets out the different levels of care provided in hospitals: Ward Care, Level 1 – Enhanced Care, Level 2 – Critical Care and Level 3 – Critical Care. It says ward care is suitable for:
• ‘Patients whose needs can be met through normal ward care in an acute hospital, • Patients who have recently been relocated from a higher level of care, but their needs can be met on an acute ward with additional advice and support from the critical care outreach team • Patients who can be managed on a ward but remain at risk of clinical deterioration.’
25. Based on what we have seen, Mr P no longer needed care that could only be provided on an ICU. He was no longer on a breathing tube, his observations were stable, his blood tests did not show anything serious, he was alert, and he had a stable night prior to discharge. Looking at the ICS statement, it appears he was well enough to go on a general ward.
Issue 2 – Mr P’s level of monitoring on the general ward
26. Mrs F complains the Trust did not properly monitor her father on the general ward. She believes he should have been placed on a monitor and/or had more regular nursing observations. The Trust says this was not clinically indicated at the time.
27. Mr P’s notes show his National Early Warning Score (NEWS) was 2 when he arrived on the ward (NEWS is a tool used to assess a patient’s degree of illness and prompt intervention from doctors when needed). However, looking at the observations taken, it appears his score should have been 4. Mr P’s respiratory rate was 24 breaths per minute (2 NEWS points as normal is 12-20) and he was on oxygen (2 NEWS points for being on oxygen).
28. The RCP guidance says a NEWS of 1-4 is a low score and patients should be monitored every 4-6 hours. We can see the Trust had Mr P on four hourly observations while his NEWS remained low. It therefore appears Mr P’s monitoring was in line with the RCP guidance up until his NEWS rose on 15 December. We will address what happened then below.
Issue 3 – Circumstances surrounding Mr P’s cardiac arrest
29. Mrs F is understandably concerned about the circumstances surrounding her father’s cardiac arrest and questions whether it was avoidable.
30. The Trust says the critical care outreach team or ‘CCOT’ (a group of experienced senior nurses who provide support to patients outside the ICU) reviewed Mr P at 2.45am on 15 December. However, at 3.10am his NEWS increased to 5 (medium score) and nursing staff noted they had escalated him (asked a doctor or CCOT to see him) though the Trust could find no record of this.
31. The Trust says CCOT would have advised nursing staff to increase Mr P’s observations to hourly. However, when nursing staff checked him again at 4am they did not complete any observations, and he was in cardiac arrest when they next checked him nearly two hours later. Staff were able to resuscitate him after four cycles of CPR (around four minutes) after finding him.
32. Mr P’s clinical records show nursing staff took his observations at 10.30am, 2.30pm, 5.15pm and 8.55pm on 14 December. They recorded his NEWS as 2, 3, 2, and 2. However, looking at the observations taken, it appears his NEWS should have been 4 (respiratory rate 24 and on oxygen), 4 (respiratory rate 21 and on oxygen), 4 (respiratory rate 21 and on oxygen) and 2 (on oxygen).
33. We will raise this possible tallying error with the Trust. However, either way, Mr P’s NEWS remained low (1-4) on 14 December and his most recently recorded NEWS at 8.55pm was 2. The records show nursing staff then checked on him at 12.30am and 2.15am on 15 December and noted he was asleep on both occasions.
34. CCOT visited Mr P at 2.45am and he was still asleep. They noted his most recent observations from 8.55pm and checked his named nurse had no concerns. They asked nursing staff to do blood tests in the morning and said they would review him again then. They also told nursing staff to escalate him if they had any concerns or if there was any deterioration in his condition.
35. Mr P’s clinical records show nursing staff next checked him at 3.10am and his NEWS had risen from 2 to 5. This is because his respiratory rate had risen from 20 to 22 (going from 0 NEWS points to 2) and his temperature had dropped from 37.2°C to 36°C (going from 0 NEWS points to 1). This took his overall NEWS to 5 when added to 2 NEWS points for being on oxygen.
36. We can see nursing staff noted on Mr P’s NEWS chart they needed to escalate his care and increase his observations to two hourly. However, there is no record they escalated him and there are no further observations before they found him in cardiac arrest at 5.50am. The notes show a nurse checked on him at 4am but did not complete any observations as he was asleep.
37. Overall, it appears there are indications of failings here and the Trust has already acknowledged this. It says its nursing staff did not escalate Mr P to CCOT as they should have done and did not increase Mr P’s observations after his NEWS rose to 5. We have therefore considered what impact this may have had on Mr P and his family.
38. Our adviser said it appears Mr P was not in cardiac arrest for long based on how quickly staff were able to revive him. They said Mr P’s cardiac arrest was a sudden and unforeseen event. They said it could not have been predicted by the relatively minor change in his respiratory rate and his temperature was still essentially normal. Overall, they did not think the nursing staff’s actions had any impact on Mr P.
39. Sadly, we cannot know what might have happened had nursing staff escalated Mr P or taken any further observations. We do not know what any further observations would have been or when CCOT would have been able to see him. We also do not know whether staff would have seen anything to indicate he was going to suffer a cardiac arrest or been able to do anything to avoid it.
40. We therefore do not think we can say, even on the balance of probabilities, that what happened with Mr P’s nursing care had any impact on his chances of suffering a cardiac arrest. A cardiac arrest usually occurs suddenly and without warning. We recognise how difficult this part of our decision will be for Mr P’s family to receive.
41. We do recognise these issues with Mr P’s care have caused, and will continue to cause, his family concern and distress. They have told us it will leave them forever wondering ‘what if?’ and we acknowledge how distressing this must be. We have therefore considered whether the Trust’s response to Mrs F’s complaint was in line with our Principles.
42. Our Principles say organisations should get it right, be customer focussed, be open and accountable, act fairly and proportionately, put things right and seek continuous improvement.
43. Our Principles also say organisations should ‘provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these.’
44. We can see the Trust has already said it considers nursing staff did not escalate Mr P to CCOT or carry out appropriate observations. It has offered its sincere apologies and said the ward sister has raised what happened with the nursing team to ensure they take learning. The Trust also considered the possible impact on Mr P and did not think the outcome would have been different had these issues not happened.
45. We think the Trust has already done enough to respond to this part of the complaint. It has explained what happened in detail, acknowledged what went wrong, apologised, considered the impact on Mr P and taken steps to stop the same things from happening again. We recognise this will not take away the distress caused to Mr P’s family.
Issue 4 – Communication with Mr P’s family
46. Mrs F complains about the way the Trust communicated with the family about Mr P’s condition following his cardiac arrest on 15 December. She has told us doctors provided contradictory information about whether he was sedated when they visited him which they found distressing.
47. Mrs F says doctors only spoke to the family about Mr P having a chest infection, and it was the hospital on the mainland that told them he had a hypoxic brain injury. She says the family felt Mr P ‘had gone’ soon after his cardiac arrest as he was completely unresponsive, but doctors gave them hope he might recover.
48. Looking at Mr P’s clinical records, there are two notes of a conversation with Mr P’s family on 18 December. The first by a nurse at 12.15pm says a doctor had told the family Mr P was off sedation, following commands and brain damage was less likely. The second is by the doctor at 12.25pm. This says they explained Mr P remained critical but had woken up and was responding to commands.
49. The first mention of a hypoxic brain injury in Mr P’s notes was on 22 December where it is listed as a possible diagnosis. There is then a note of a conversation between a doctor and one of Mr P’s daughters later that day. The notes say the doctor told her a repeat head CT had not shown any new bleed or stroke, but he was still not waking up appropriately on sedation.
50. There is then a note of a telephone conversation between a doctor and one of Mr P’s daughters on 23 December. The note says Mr P had most likely suffered hypoxic brain damage due to CPR as well as having a severe chest infection and his chance of recovery was very poor. Our adviser clarified the injury was not due to CPR but the cardiac arrest itself.
51. It can often be difficult for us to comment on communication issues as we usually do not know exactly what was said or how. We know there can be different interpretations of the same conversation. We also recognise communication can be more challenging in situations where people are distressed, where conversations take place over the phone or where conversations are with different people.
52. The GMC professional standards say doctors ‘must give patients the information they want or need to know in a way they can understand’ (or those close to the patient when the patient is unconscious or lacks capacity). They also say doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
53. Our adviser said most cardiac arrests sadly lead to the patient dying. They said the fact Mr P was successfully resuscitated and it appears his cardiac arrest was relatively short means it was reasonable for doctors to be initially optimistic. They also said entries on 18, 19 and 21 December saying Mr P had woken up and was responding to commands were also encouraging. We therefore think the Trust’s early positive messaging was appropriate.
54. However, the note of the conversation on 22 December includes medical phrases such as ‘sedation hold’ and ‘not waking up appropriately’. We therefore think the information doctors provided about Mr P’s sedation may have been confusing. We also know Mr P’s family were left unclear about the doctor’s reference to him having no ‘new’ bleed or stroke (they meant the CT showed no changes when compared to the previous scan on 12 December).
55. From what we have seen, the Trust shared information about the likely hypoxic brain injury the day after doctors considered it a possibility. However, there are clear discrepancies in respect of what was said, by whom, and how on 23 December. We do not believe it is possible for us to reconcile those accounts and determine what happened or likely happened.
56. It is clear Mr P’s family did not fully understand what was happening to him while he was at the Trust. It is difficult for us to say whether this was down to poor communication, the challenges of communicating with different people in person and by telephone, family members being understandably distressed or a combination of these things.
57. We do not think we can say communication was so poor it fell below the GMC professional standards. We also recognise the Trust explained what happened in its complaint response and apologised the family were left not knowing what was happening. This is in line with our Principles.
Overall
58. We have seen some indications of failings by the Trust. It has acknowledged its nursing staff did not escalate Mr P or take appropriate observations. We cannot say this had an impact on Mr P though we recognise it has caused, and will continue to cause, his family distress. We consider the Trust has already responded to this part of the complaint in line with our Principles.
59. We have also seen the Trust’s communication with Mr P’s family could have been better. We do not think we can say it was so poor it fell below the GMC professional standards. However, we do recognise the distress it has caused, and continues to cause, Mrs F and her family. We consider the Trust has already provided a detailed explanation of what happened and apologised.
60. We sincerely hope our consideration brings Mrs F and her family at least some reassurance around what happened to Mr P. We would like to thank them for bringing their concerns to us. We know raising a complaint about a loved one’s care can be a difficult and lengthy process. We would like to take this opportunity to wish them the very best for the future.