Treatment of UTI
25. Mrs D is concerned the Trust did not appropriately treat her brother’s UTI during his admissions on 27 December 2021 and 4 January 2022 and this caused sepsis.
26. The Trust’s response did not address this specific concern but said it provided Mr A with the correct treatment throughout his inpatient stay.
27. GMC guidance sets out how a doctor can provide good care. Under section 15, it says doctors must provide suitable advice, investigation and treatment where necessary.
28. Following Mr A’s admission on 27 December, we can see staff carried out a number of tests. This included blood tests, which showed he had a C-reactive protein (CRP) level of 43, which is mildly elevated.
29. CRP is produced by the liver in response to inflammation in the body. It is a good indicator of whether there is active infection in the body.
30. The records note Mr A’s urine was cloudy on 28 December, although we can see no evidence staff sent this for analysis.
31. Our physician adviser says it is not always helpful for cloudy urine to be analysed in patients who have a long-term catheter like Mr A.
32. For example, catheters are often colonised by bacteria which means bacteria are present in the urine but are not causing infection. As such, identifying growth of bacteria in a urine sample is not sufficient to prove infection.
33. Based on Mr A’s low CRP level and because he was already receiving prophylactic (preventative) trimethoprim and nitrofurantoin antibiotics for UTIs, there does not appear to be an issue with his treatment during this initial admission.
34. Mr A appears to have been well prior to his discharge to the nursing home on 28 December. We can see nursing home staff discussed Mr A’s condition over the phone with a hospital nurse earlier that day who reported Mr A was ‘alert, coherent and chatty’.
35. This looks to be supported by nursing home staff who reported Mr A was ‘chatty’ after his arrival back at the nursing home.
36. It was not until around six days later (3 January) the nursing home reported he had become unwell again.
37. This indicates doctors provided Mr A with the correct treatment. We are satisfied Mr A’s treatment up to this stage was in line with GMC guidance.
38. Following Mr A’s readmission on 4 January, staff took blood tests and a urine sample, and doctors discussed his antibiotics with the microbiology team. They decided they should hold off any further antibiotic prescription until they obtained urine or blood cultures to see if a specific organism could be identified.
39. If Mr A needed further antibiotics, this would have allowed doctors to give more targeted treatment.
40. Following microbiology advice, we can see doctors prescribed intravenous (IV) Meropenem (a strong broad-spectrum antibiotic) on 6 January. This appears to have been combined with IV Amikacin (another potent broad-spectrum antibiotic) on 8 January.
41. Both antibiotics were used for several days until doctors switched to palliative care around 11 January after Mr A’s condition significantly deteriorated.
42. Our physician adviser notes the length and nature of the IV antibiotic regime appears entirely in keeping with treating a severe and potentially resistant UTI.
43. We are satisfied doctors treated Mr A’s UTI in line with GMC guidance.
44. We recognise Mrs D is concerned a lack of treatment around Mr A’s UTI led to her brother developing sepsis. As we have set out above, there is no evidence to suggest any poor care of Mr A’s UTI. We hope this provides Mrs D with some reassurance.
Unsafe discharges 45. Mrs D tells us the Trust should not have discharged her brother on 28 December 2021 and 4 January 2022.
46. Mrs D is concerned her brother repeatedly became unresponsive and this was indicative of a decline in his health. She says her brother’s reaction to infection was to become unresponsive and the Trust appears to have ignored this before discharging him.
47. Mrs D also says medical staff failed to notify her brother’s nursing home before discharging him early in the morning on 4 January and did not provide discharge paperwork. She says it was important to ensure his nursing home staff knew when he would arrive and was aware of what treatment he had received.
48. The Trust says Mr A received the correct care during both admissions and it was right to discharge him. It acknowledged, however, that it did not notify Mr A’s nursing home prior to his discharge on 4 January or supply the relevant discharge paperwork.
49. The Trust apologised for its mistake and said it had discussed this matter with ED staff to avoid any recurrence.
50. Section 21 of GMC guidance says medical records should include relevant clinical findings. Section 15 of GMC guidance which is set out at paragraph 27 is also relevant here.
51. Part 25 of RCEM guidance says discharge planning should be communicated with carers, relatives and healthcare providers.
52. We see the Trust’s lack of contact with nursing home staff and a lack of discharge paperwork as a failing. We will consider their impact later in our report.
53. We will now review these two discharges in more detail.
28 December discharge 54. Nursing home staff reported Mr A had been unresponsive for around 30 to 35 minutes before returning to his baseline (his usual state).
55. Upon arriving at hospital, our physician adviser says medical staff carried out the tests they would expect to see including a physical examination, blood tests, and a computed tomography (CT) scan which did not find anything of concern. A CT scan uses X-rays and a computer to create detailed images of the body.
56. The previous section of our report at paragraphs 25 to 44 provides detail around the tests and their results, so we will not repeat them here.
57. The records also appear to show Mr A was conscious and answering questions during this admission. He is reported as feeling ‘alright’ and is also reported to have been ‘chatty’ after being discharged. As set out at paragraph 36 he appeared well for the preceding six days following his discharge on 28 December.
58. All of this indicates the doctors’ assessment and decision to discharge Mr A was correct and in line with GMC guidance.
4 January discharge 59. The reasons for Mr A’s admission on 4 January were different to 27 December.
60. Nursing home staff called an ambulance as they reported Mr A was ‘unresponsive to voice and stimuli…’ 61. His Glasgow Coma Scale (GCS) was recorded as 12/15, improving to 13/15 on arrival in the ED. This would suggest Mr A was responding with inappropriate words in the ambulance and was confused on arrival in the ED.
62. There was a further GCS recording of 10/15 following his arrival in the ED, which indicates he was not speaking.
63. GCS is a tool used to assess a patient’s level of consciousness, especially after a head injury or in cases of neurological deterioration. It helps clinicians evaluate and track changes in a patient's neurological status over time.
64. Our ED adviser could find no definite confirmation in the records Mr A returned to his normal conscious level (alert and able to vocalise) prior to being discharged back to the nursing home. They also note there was no evidence to suggest the assessing doctor contacted the nursing home so they were aware of, and could better identify his normal conscious state.
65. Aside from Mr A’s conscious levels, we can see medical staff carried out the tests we would expect to see including blood tests and a CT head scan which found no concerns.
66. We have been unable to clearly identify in the records whether Mr A returned to his normal conscious level prior to his discharge at 4.20am on 4 January. This as a failing as it is not in line with section 21 of GMC guidance.
67. We have not seen any evidence this had a clinical impact upon Mr A.
68. Our renal physician adviser notes that, overall, the lack of clarity in the records around Mr A’s consciousness levels do not appear to have had any significant clinical impact upon him going forward.
69. This is because Mr A is reported to have, ‘presented as coherent and responsive throughout the morning, eating and drinking and answering questions’ following his arrival back at the nursing home. Alongside this, there is nothing to suggest he needed further treatment during this earlier admission.
70. Once Mr A was back at the nursing home, it was not until 5.30pm that day that he again became unresponsive and was taken back to hospital.
71. On balance, we are persuaded that overall, the doctor’s decision to discharge Mr A was correct and in line with section 15 of GMC guidance.
72. We are concerned, however, that medical staff did not discuss matters with nursing home staff before Mr A was discharged and did not provide them with discharge papers in line with RCEM guidance. This as a failing.
73. We will revisit this later in our report where we will consider what impact these events had and what will put it right.
Bypassing suprapubic catheter 74. Mrs D tells us medical staff ignored the constant bypassing of her brother’s suprapubic catheter, and this caused him to be soaked in urine every day. She says this likely contributed to his development of sepsis.
75. The Trust says Mr A’s suprapubic catheter was draining well during his hospital admissions.
76. RCN guidance sets out the importance of carefully recording key information around suprapubic catheter use such as risk assessments and care plans or care bundles.
77. Such information would be expected to detail the specific care to clean the supra pubic site, record any signs of infection or document there were no concerns, record the colour and consistency of urine and if the patient was experiencing any discomfort.
78. Additionally, such record keeping should clearly set out when the equipment should be changed and any due dates for this. For example, a suprapubic catheter would need changing every 12 weeks and the drainage bag should be changed weekly.
79. NMC guidance sets out how nursing staff can provide good care. Section 10 says medical records should be completed accurately and in a timely manner.
80. There is no detailed documentation in Mr A’s medical record which covers the above considerations.
81. We have seen sporadic references in the nursing records of the catheter ‘draining well’, of it bypassing on two occasions and one reference to ‘bag emptied’, but these records are inconsistent. Our nursing adviser explained they do not give the level of detail we would expect to see.
82. The Trust’s record keeping is not in line with RCN guidance or NMC guidance. Therefore, based on the evidence we have seen, we are not reassured the Trust managed Mr A’s suprapubic catheter in line with applicable guidance. This is a failing.
83. We sought some advice from our renal physician adviser to better understand whether any potential bypassing of the suprapubic catheter could have contributed to or caused sepsis.
84. Our renal physician adviser explains there can be a relationship between poor catheter care and the development of infection.
85. This being said, they note it is very difficult to relate any specific potential failing in care here as being directly causative, even on the balance of probabilities, to Mr A’s sepsis.
86. This is based on the multitude of factors presented in Mr A’s care which include his serious and longstanding conditions, his history of recurrent UTIs and that not all infection is preventable.
87. We can see two references in Mr A’s records of his bypassing suprapubic catheter. We balanced the lack of detailed records concerning Mr A’s suprapubic catheter alongside Mrs D’s account she regularly witnessed it bypassing. We are persuaded the suprapubic catheter bypassed on more occasions than the records suggest.
88. We recognise the bypassing suprapubic catheter will have been both upsetting and distressing to Mrs D and Mr A at an already difficult time. We cannot say, even on balance, it either caused or contributed to Mr A’s sepsis.
89. We recognise, however, that the Trust’s poor record keeping has limited the insight we can provide Mrs D in terms of how it managed Mr A’s suprapubic catheter. We acknowledge this is likely to cause additional upset.
90. We will further explore the emotional impact to Mrs D later in our report where we will also consider what remedy we think will put it right.
Food and drink 91. Mrs D says the Trust’s SALT team gave Mr A food and drink on 5 January despite knowing he was unable to swallow due to his low level of consciousness.
92. Mrs D is concerned Mr A developed aspiration pneumonia as a direct result of this, which then contributed to his death.
93. Aspiration pneumonia is a lung infection which occurs when substances such as food, liquid and saliva are inhaled into the lungs instead of being swallowed.
94. The Trust says its SALT team knew Mr A well due to his previous admissions and long-standing difficulties with swallowing. It said it put a modified diet and fluid plan in place in 2021 following consultation with family and medical staff, and staff acted in line with this when giving him food and drink on 5 January.
95. We understand this plan assessed Mr A’s risk and quality of life and found a modified food and fluid diet to be a reasonable balance between the two and accepted the risks associated with aspiration.
96. Mrs D does not dispute what is set out in this plan but reiterates staff should not have given her brother food and fluid at this time owing to Mr A’s poor level of consciousness. She believes there was a rush to get Mr A eating so the Trust could discharge him more quickly, and it is this approach which led to aspiration pneumonia.
97. Section one of NMC guidance says nurses must deliver the fundamentals of care effectively. Fundamentals include the provision of nutrition and hydration. Section eight says nurses must refer matters to their medical colleagues where appropriate.
98. HCPC guidance sets out how SALT staff can provide good care. Section 14.2 says SALT staff should conduct appropriate diagnostic procedures to inform treatment or therapy.
99. Our SALT adviser says it would not be standard practice to refer a patient to SALT without an initial trial to check if they are able to handle their usual food and drink consistencies.
100. Mr A’s usual food and drink consistency while in hospital is recorded as a pureed diet with thickened fluids which appears to be consistent with his 2021 modified diet and fluid plan.
101. The medical record on 5 January notes Mr A was ‘now awake’ and plans were made to ‘try with oral intake as per usual level’.
102. Our SALT adviser explains it was not unreasonable at this stage to trial Mr A’s usual food and drink consistencies.
103. A nurse gave Mr A four mouthfuls of food and some fluids, but found he was holding it in his mouth before swallowing. In response, the nurse made a SALT referral which is in line with section eight of NMC guidance.
104. We can see staff appear to have given Mr A an appropriate consistency of both food and fluids on 5 January in line with his previously agreed plan.
105. We acknowledge Mrs D’s concerns that Mr A was unable to swallow due to his fluctuating consciousness. Having carefully considered this, we are persuaded the nurse’s attempt to feed Mr A appears to be reasonable under the circumstances and they correctly notified SALT when they had concerns about his swallowing. All of this appears to be in line with NMC guidance.
106. A SALT assessment the next day confirmed Mr A’s pre-existing diet plan remained in place, and this was made ‘with acknowledged risks’. This meant that while Mr A could manage these textures, it did not eliminate the possibility of aspiration. We are satisfied the Trust carried out this assessment in line with HCPC guidance.
107. Our SALT adviser explains the small amount of food and fluids staff gave to Mr A during this admission is unlikely to have directly caused his aspiration pneumonia. They note it is more likely there were other factors which contributed to the development of this condition such as oral health and Mr A’s overall physical health at the time.
108. We are satisfied nursing and SALT staff acted in line with applicable guidance on 5 January.
109. We appreciate our findings will likely come as little solace to Mrs D as we acknowledge doctors suspected Mr A was suffering from aspiration pneumonia later in his admission. We hope she can gain some reassurance from our final report that clinical staff acted correctly on 5 January.
Epilepsy medication 110. Mrs D is concerned medical staff missed at least six doses of her brother’s epilepsy medication between 27 December and 7 January.
111. She says doctors told her they had been unable to give Mr A his epilepsy medication because he was, at times, unable to swallow. She also says IV epilepsy medications were at times unavailable on the ward, which likely contributed to those missed doses.
112. Mrs D explains the failure to correctly administer her brother’s epilepsy medication caused regular seizures and once started, they could not be stopped.
113. The Trust was unable to identify any occasions where it missed Mr A’s epilepsy medication. It adds that by the 11 January a palliative approach had been taken as medical staff felt Mr A was sadly dying. It therefore did not provide further epilepsy medication from this date. It says it discussed this approach with Mrs D at the time.
114. Section 15 of GMC guidance which is set out at paragraph 27 is also relevant here.
115. GMC’s end of life guidance says doctors should ensure palliative patients are treated with the same level of care as other patients and are kept as comfortable as possible in the time they have left.
116. Phenytoin and valproate were the two key drugs used to treat Mr A’s epilepsy.
117. During the first admission period (27 to 28 December) Mr A was admitted at 6.40pm on 27 December and was ‘clerked in’ (the process of admitting a patient by taking a comprehensive medical history and performing a full physical examination) by the medical team at 1.00am on 28 December.
118. We were unable to find any record of staff giving him phenytoin or valproate on 27 December, but he received both on the morning of 28 December. Mr A was discharged shortly afterward at 11.40am.
119. During the next admission period (4 January to 18 January) it appears Mr A was in an ED bed at around 6.50pm on 4 January and a ward bed was requested at 2.30am on 5 January. The medication charts first mention phenytoin and valproate on 5 January and note staff gave neither drug that day because Mr A was too drowsy.
120. Both drugs appear to have restarted on 6 January at around 2.40am where Mr A was given IV valproate and phenytoin. The valproate continued with four IV doses on 6 and 7 January. The next dose of phenytoin appears to be at 1.30am on 7 January (and then at 1.40pm and 10pm later that same day).
121. We can see staff correctly administered phenytoin and valproate between 8 and 11 January.
122. There appear to be some missed doses of Mr A’s epilepsy medications on 27 December and 4 and 5 January. There also appear to be periods where doses were not given consistently at the same time. This is as a failing as it is not line with GMC guidance.
123. Our neurologist adviser says that while it is important for epilepsy medication to be given consistently, it does not necessarily follow that the occasional missed dose or a dose given at a different time will have a significant effect. They note that phenytoin has a half-life (the time it takes for the concentration of the drug in the body to be reduced by half) of 7-42 hours and valproate has a half-life of 13-19 hours.
124. In the circumstances presented here Mr A is likely to have still benefitted from those drugs even when doses were missed.
125. We are not convinced those missed or inconsistent doses would have significantly affected Mr A’s clinical outcome or contributed to his death.
126. We do recognise it had an emotional impact upon Mrs D.
127. She was aware at the time of the missed and inconsistent doses and this likely added to her upset and distress at an already difficult time.
128. We will further explore the emotional impact these events had upon Mrs D later in our report where we will also consider what remedy will put it right.
129. We also acknowledge a specific incident Mrs D describes on 11 January.
130. She explains IV epilepsy medication had been delayed on 11 January and Mr A was suffering seizures.
131. We can see doctors met with Mrs D on 10 and 11 January, and by 11 January it was decided a palliative approach would be taken due to Mr A’s deterioration. The plan was to give Mr A midazolam (a sedative) and levetiracetam (anti-seizure medication) to keep him as comfortable as possible.
132. The incident Mrs D describes on 11 January appears to be at the point Mr A was changed from his usual epilepsy medication regime to a palliative one. His seizures appear to have come under control on 11 January after staff gave him midazolam and levetiracetam.
133. We are satisfied doctors appropriately switched from Mr A’s usual epilepsy medication regime to a palliative one to keep him as comfortable as possible. This in line with both GMC guidance and the principles set out in GMC’s end of life guidance.
134. We are aware these events were incredibly upsetting to Mrs D and have been a source of continued distress. We hope our final report provides some reassurance in these matters.
Doctors refused to admit Mr A to its ICU on 7 January 135. Mrs D told us her brother was suffering uncontrolled seizures and was struggling to breathe. She says ward doctors requested Mr A be moved to the ICU, but this was declined by ICU staff as they felt he was unsuitable.
136. Mrs D explains ward doctors and nursing staff felt they could not appropriately care for Mr A. She says this was distressing and she ‘personally pleaded’ with ICU staff to take him but they refused.
137. The Trust’s ICU consultant reviewed Mr A on 7 January and decided its ICU could provide airway support if his airway became compromised during treatment for his seizures.
138. The ICU consultant found no evidence Mr A’s airway was compromised at the time and noted his treatment escalation plan (which had been agreed by his ward medical team) did not see referral to ICU ‘for any other treatment’ was in his best interests.
139. The Trust says it made the correct decision not to admit Mr A to its ICU and staff appropriately cared for him on the ward.
140. Our ICU adviser says there are no specific or definitive guidelines as to which patients should be admitted to ICU.
141. They explain admission to the ICU should be based on good decision making which takes into account the possibility of reversing the presenting illness, the overall condition of the patient, whether they will be able to rehabilitate appropriately, and, whether the burden of intensive care outweighs the possible benefits. Our ICU adviser also says discussion with the patient, or those closest to them should also be factored in.
142. Section 33 of GMC guidance says doctors must be considerate to those close to the patient and be sensitive in giving them information and support. Section 15 of GMC guidance which is set out at paragraph 27 is also relevant here.
143. Following discussion between the ICU consultant and Mr A’s ward medical team on 7 January it was agreed he would not benefit from ICU care other than the possibility of airway support.
144. As set out above, there was no evidence Mr A’s airway was compromised at the time. A treatment escalation plan had already been completed by Mr A’s ward medical team who thought escalation to ICU would not be in his best interests.
145. The Trust’s ICU consultant agreed with the treatment escalation plan and appears to have discussed it with Mrs D where it was confirmed ICU support would be considered if Mr A needed airway protection or support. We understand Mrs D disagreed with the ICU Consultant’s decision and this will have been distressing for her.
146. We have seen no evidence to suggest ward doctors and nursing staff were unable to cope with Mr A’s care at this time.
147. Overall, we are satisfied ICU doctors correctly reviewed Mr A’s suitability for ICU admission in line with GMC guidance. This includes discussing matters with his ward based medical team and Mrs D.
No learning disabilities nurse 148. Mrs D is concerned the Trust did not have a learning disabilities nurse to advocate and support Mr A while he was a patient. She is concerned a lack of support may have impacted upon his access to good healthcare.
149. The Trust apologised to Mrs D during the complaints process in 2022 as it did not have a learning disability nurse in post at the time of Mr A’s admissions. Instead, it explained it had a ‘vulnerable adult team’ who were supporting the wards while it was attempting to fill the learning disability nurse vacancy.
150. Following further discussion with the Trust, we understand Mr A did not receive support from its vulnerable adult team during his admissions. The Trust says Mr A should have received such support and provided an apology to Mrs D that this did not happen.
151. This represents a failing as our Principles say public bodies should provide effective services with appropriately trained and competent staff. We recognise the Trust agrees there was a failing in its service here and says Mr A should have received this kind of specialist support.
152. We considered whether there is evidence this lack of support presented a barrier to Mr A receiving good healthcare. Our physician adviser found no evidence to indicate such barriers were present.
153. We are therefore not persuaded there was any clinical impact caused to Mr A by a lack of support from the Trust’s vulnerable adult team.
154. While we have found no evidence Mr A came up against any barriers which prevented him from receiving good healthcare, we acknowledge the Trust made efforts to improve its service for patients with learning disabilities in 2022.
155. We asked the Trust for clarification on what progress it has made.
156. The Trust tells us it now has two learning disabilities nurses which it hopes will reduce any health inequalities, support reasonable adjustments and stop ‘diagnostic overshadowing’ where a patient’s ill health is attributed to their learning disability and may lead to inequitable treatment.
157. It also says it is providing its staff with learning disability and autism training to raise awareness of learning disabilities and how to provide better care. The Trust recently confirmed this training is still ongoing, and it has so far (at the time of writing this report) trained over five thousand members of its staff.
158. Our Principles also say public bodies should review their policies and procedures regularly to ensure they are effective and use feedback to improve the service they provide to the public.
159. Based on what we have seen, we are satisfied that while there do not appear to have been barriers in Mr A’s care the Trust were receptive to Mrs D’s concerns and proactively made efforts to improve its service in this area. Those improvements are in line with our Principles.
Impact 160. We are aware Mrs D was very much involved in her brother’s care during the period in question and was regularly at her brother’s bedside. She was therefore acutely aware of the problems her brother faced at the time.
161. We understand she was very concerned about her brother’s discharges in December 2021 and January 2022 and whether something had been missed.
162. While we have seen no evidence to suggest Mr A was incorrectly discharged, we have seen staff failed to notify his nursing home of his impending discharge and provide it with the correct paperwork.
163. We cannot see this had a clinical impact upon Mr A. The lack of discharge paperwork and notifying nursing home staff caused some of the upset Mrs D describes as she was worried about her brother’s condition and how this was managed at hospital. The lack of discharge paperwork and notifying nursing home staff added to her deepening worry around her brother’s ongoing care.
164. We acknowledge the Trust provided an apology for the lack of contact with Mr A’s nursing home and for the lack of discharge paperwork during the complaints process. We noted it had spoken with its ED staff to avoid a similar occurrence.
165. Having carefully considered this, we see the apology it already provided is sufficient. It is inline with our Principles of remedy which say public services should attempt to put things right by providing an apology, explanation, and acknowledgement of responsibility.
166. We also see further service improvement around this matter is needed. We recognise the Trust discussed matters with its ED team in 2022 to avoid recurrence. We think it needs to explain the steps it has taken more clearly and provide measurable evidence of how it will avoid such mistakes from being repeated.
167. We cannot say any mismanagement of Mr A’s suprapubic catheter led to or contributed to sepsis. We can say poor record keeping identified in this report further compound Mrs D’s upset as it has meant we are unable to give a more detailed response to her concerns.
168. In terms of staff’s management of Mr A’s epilepsy medications, we are very much aware this is one of Mrs D’s key concerns. She already suspected there were missed and delayed doses, which she said was very upsetting and worrying.
169. We hope our report will in some way reassure Mrs D those mistakes did not have a serious clinical impact upon Mr A. We acknowledge the emotional impact of worry and distress those missed and delayed doses had upon her. As set out above, Mrs D was very much involved in her brother’s care and was aware of the problems concerning his epilepsy medications.
170. We must be mindful that much of the emotional impact suffered by Mrs D came at an already difficult time when her brother was very ill. We understand these events have been incredibly upsetting to both Mrs D and her wider family.
171. Mrs D wants the Trust to acknowledge its errors, apologise for them and make service improvements. Based on the information we have seen, we agree these actions are proportionate to put right the impact of the failings we have identified.
172. The next section of our report will outline what recommendations we think will put right what went wrong.