Outpatient appointments in November 2021 and May 2022 27.Mrs L complains the medical team dismissed Mrs H’s symptoms during outpatient appointments she had.
28.Mrs H had an outpatient appointment on 9 November 2021. The Trust said that at this, her history was reviewed, and noted she had a short oesophagus (tube that connects the throat to the stomach) and a minor degree of hiatus hernia postoperatively. During the appointment, the plan was made to continue to monitor her, she was advised to inform the medical team if her condition deteriorated, and another appointment was made for six months’ time.
29.Mrs H was reviewed again in clinic on 23 May 2022. The Trust said she had a long discussion about her symptoms (including her weight loss, pain and retching). An urgent gastroscopy was arranged to understand the situation and to be able to construct a further management plan.
30.We considered this issue with help from our surgeon adviser.
31.GMC good medical practice guidelines explain that when doctors assess, diagnose or treat patients, they must adequately assess the patient’s condition, taking account of their history and where necessary examine the patient. They should also promptly provide or arrange suitable advice, investigations or treatment where necessary and refer a patient to another practitioner when this serves the patient’s needs.
32.On 9 November 2021, the medical records show the doctor carried out an appropriate assessment during the outpatient appointment. This included noting Mrs H’s medical history, and what treatment had previously been done. The records indicate she was quite satisfied with her symptoms and had maintained her weight, which was stable.
33.There was also a conversation about the pros and cons of further investigations, and it was decided not to carry out anything further, at that point. A decision was made to see Mrs H again in six months’ time, with a specialist consultant. She was also advised to get back in touch if she had any further symptoms in the meantime, so appropriate safety netting was also in place.
34.On 23 May 2022, an appropriate assessment was again undertaken. It was noted that Mrs H was getting more symptoms which had got worse, and she was losing weight. This is important, as this is an indication of not getting enough nutrition. It was therefore appropriate during this appointment to decide to carry out further investigations and arrange a gastroscopy.
35.There is no evidence that Mrs H’s symptoms were dismissed during these appointments. Her history and symptoms were noted, appropriate assessments carried out and further investigations planned as required. These actions are in line with the GMC guidance, highlighted above.
Delay in Mrs H’s surgery for a hiatus hernia from November 2021 to August 2022 26. Mrs L is unhappy that Mrs H’s surgery was delayed from November 2021 to August 2022.
27. The Trust explained the decision was made to optimise Mrs H’s nutrition and general fitness and attempt further repair of the recurrent hiatus hernia as this had increased in size and she had more symptoms. She then contracted COVID-19, and the medical team discussed this with the anaesthetic team. It said in accordance with guidelines from the association of anaesthetics of Great Britain and Ireland, it was considered in Mrs H’s best interest to defer surgery, whilst maintaining nutrition through NJ feeding and oral supplements. She tested negative for COVID-19 on 28 July, and an earliest date for surgery based on the guidance, was 2 September 2022.
28. As highlighted above, GMC good medical practice guidelines explain that doctors should carry out appropriate assessments, arrange suitable advice, investigations or treatment where necessary and refer a patient to another practitioner when required.
29. During the November 2021 outpatient appointment, it was reasonable to wait and see what happened. Mrs H’s symptoms were manageable at that time, and she had only had surgery a few months prior, which could not be fully completed. Further surgery is less likely to be successful again in such a short time frame. She was also asked to get in touch with the medical team again, if her symptoms got worse.
30. In May 2022, there was an increase in her symptoms, and she was losing weight, so it was reasonable to undertake further investigations then, and following the results, a decision was made to operate.
31. When Mrs H was admitted to the Trust on 13 June, she had been losing weight. It was reasonable to optimise her nutrition and general fitness before carrying out surgery, to help reduce the likelihood of complications during and after surgery. She had an NJ tube fitted for feeding and it takes some time to see the effects of this and the difference it makes to nutritional status. It was therefore reasonable to wait for her nutrition to be improved, before carrying out surgery.
32. On 17 July, Mrs H contracted COVID-19, and tested negative for the infection on 28 July.
33. COVID-19 surgery guidance at the time, advised that patients who had contracted COVID-19 should wait at least seven weeks after the infection, before undergoing surgery. Mrs H was a high-risk patient due to her age and the type of surgery that was due to be carried out. It was therefore appropriate to wait, and this decision was in line with the guidance at the time.
34. It is not noted in Mrs H’s medical records that a conversation was held with her about this, however it is likely the same decision would have been made. This is because her condition was not life threatening, she was stable at that time and her nutrition needed to be optimised first, before surgery could be carried out.
35. We understand Mrs L’s concern that Mrs H’s surgery was delayed and sadly could not be carried out before she died. We think the evidence indicates the correct decisions to wait for surgery, were made in line with the guidance at the time.
Investigations and treatment into Mrs H’s symptoms when she was admitted in June 2022 36. Mrs L complains that when Mrs H was admitted to the Trust on 13 June, the medical team did not adequately investigate her symptoms and initially treated her on the incorrect ward.
37. In its complaint response, the Trust said that overall, there was evidence of a clear and appropriate management plan, including early and appropriate referral to the surgical team and intensive care doctors. It said the volvulus and consequent chest infection, were not present at the time of Mrs H’s admission and she sadly deteriorated rapidly after developing a bowel obstruction.
38. Mrs H attended ED on 13 June and was admitted to a surgical assessment unit on 14 June, before being transferred to a gynaecological ward. On 19 June, she was transferred to the surgical ward. It appears she was waiting for a suitable bed to become available, before she was transferred.
39. We refer to GMC good medical practice guidelines in considering this issue, which explains that adequate assessments should be carried out, and investigations and treatment promptly provided to patients, where necessary.
40. On Mrs H’s admission, her history was taken into account, and her symptoms assessed. It was noted she was already under the medical team for her preexisting condition and a gastroscopy and blood tests were carried out. This showed she had a hiatus hernia, and the medical team, with input from the surgical team, put a plan in place for her to have surgery.
41. As she had been losing weight, it was right to try and optimise her general health and nutrition before surgery was attempted. This is because it would have been higher risk to carry out the surgery earlier, when she was not in good health. The plan going forward was therefore appropriate.
42. Her assessment was appropriate, as were the investigations into her symptoms which revealed the hiatus hernia. Mrs H was known to the medical team, and they planned to operate once her nutrition and general health, improved. There was no indication at that time that she had any other health conditions that needed to be treated. The investigations and plan for treatment, was in line with GMC good medical practice guidelines.
43. GMC good medical practice guidelines also state that doctors must make good use of the resources available to them.
44. We recognise Mrs L’s worry that Mrs H was not on the surgical ward straight away. Unfortunately delays like this can occur due to demand on the Trust’s service, causing a wait on some beds.
45. The evidence in the medical records shows that Mrs H was still getting the appropriate care she needed while waiting for a surgical bed, and the surgical team also reviewed her regularly. There is nothing to suggest that not being on the surgical ward straight away, had a negative impact on her clinical condition.
46. Overall, the evidence shows the medical team investigated the symptoms that Mrs H presented with, put a treatment plan in place and cared for her correctly, until a surgical bed became available. This is in line with GMC good medical practice guidelines.
Nutritional care 47. Mrs L complains the Trust provided poor nutritional care to Mrs H during her inpatient stay and when it transferred her to the rehabilitation hospital. This includes five days with no nutrition, failings in total parenteral nutrition, and incorrect and unsuitable foods administered. She also complains the Trust failed to send any nutrition and sterile water for the NJ tube to the rehabilitation hospital.
48. We considered these issues with help from our nursing and dietitian advisers.
Five days without nutrition
49. In its complaint response, the Trust said the NJ tube was inserted on 17 June. It said there was a delay in the NJ feed being started as the nurse did not know NJ feeds could be given on the ward and there was some confusion between staff. The NJ feed was started on 18 June, along with fluids and oral supplements. It further said Mrs H remained on the NJ feed while waiting for surgery and there is no clinical harm with long-term NJ tube feeding.
50. The NMC code states that nurses should treat people as individuals and uphold their dignity. To achieve this, they must make sure they deliver the fundamentals of care effectively. This includes but is not limited to, making sure those that are receiving care, have adequate access to nutrition and hydration.
51. Mrs H was admitted to the Trust on 13 June as she had been vomiting for three days prior to the admission and could not tolerate oral nutrition. In the medical records it was documented that she was keeping fluids down ‘at present’.
52. It was further documented at 8.45am on 14 June, that Mrs H had some toast in the morning and was then nil by mouth (NBM – a patient is instructed not to consume any food, drinks or medications orally) from midnight due to having a planned gastroscopy the following day. She returned to the ward following the procedure on 15 June and remained NBM whilst awaiting a medical review. This is because food residue was still noted in her stomach and NBM was required with sips orally, to clear the food residue.
53. The medical plan following the review was for clear fluids and total parenteral nutrition (TPN – nutrition that is given intravenously and should be the sole source of nutrition).
54. Given that the nutritional plan was for TPN and not all nursing staff are trained in the administration of TPN (including the staff on the ward she was on), nursing staff arranged for a surgical bed, where TPN could be facilitated, and updated her family two hours after the medical review on 15 June. The surgical team had already referred Mrs H to the dietitian to arrange the feeds.
55. On 16 June at 9am, the medical team reiterated that Mrs H was ‘awaiting TPN’ and documented she could be given Fortisips (brand of nutritional supplement drinks) twice a day until then ‘if tolerated’. The medical plan changed to an endoscopic NJ (feeding tube inserted through the nose, down the throat and into part of the small intestine) later that morning. Nurses documented at this time, that Mrs H was only tolerating clear fluids and Fortisips.
56. The above sequence of events outlines that nursing staff followed surgical advice by providing clear fluids and Fortisips to Mrs H as tolerated.
57. At 6.10pm on 17 June, Mrs H had an NJ tube placed and was waiting for a doctor to review her before feeds could start. She was seen by the nutritional team who planned her feeding regime noting that she was at high risk of refeeding syndrome (when a patient who is malnourished begins feeding again and if food is introduced too quickly, it can cause serious complications). The plan was for the feeds to start that evening. On the morning of 18 June, the surgical team documented ‘start NJ feeding as regime’.
58. In summary, the records show that nurses followed medical advice from admission, through until 17 June. Toast was given on the morning of the 14 June, and then Mrs H was NBM. Clear fluids and Fortisips were given when advised by the medical team. The NJ tube was inserted on 17 June and the feed started on the morning of 18 June. The actions taken were therefore in line with the NMC code and Mrs H was not left for five days with no nutrition.
59. We acknowledge there was a delay of a few hours in the NJ feed being started. We recognise this is upsetting for Mrs L, but we think this was an error, rather than a failing in care. We also note the Trust appropriately apologised for this and said that further education was given to staff in relation to using an NJ tube.
60. We also looked at the input from the nutrition team.
61. NICE nutrition support guidance states that people at high risk of developing refeeding problems, should be cared for by healthcare professionals who are appropriately skilled and trained and have expert knowledge of nutritional requirements and nutrition support.
62. HCPC standards also say that healthcare professionals, including dietitians, work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other service provided. Healthcare professionals should also communicate effectively with colleagues, sharing relevant information in a clear and timely manner. It also notes that where possible, plans be co-created, and the patient should be at the centre of their care. There is no evidence within this review that the plan was discussed with Mrs H.
63. A referral to the dietitian team was made on 15 June due to a request for TPN. The Trust explained it carried out an initial assessment on 16 June where estimated nutritional requirements were calculated and an NJ feeding plan was written and discussed with Mrs H. A further assessment was carried out on 17 June. This contained a safe plan and commented that NJ feeding was to be placed rather than TPN being provided. It also correctly identified Mrs H’s refeeding risk and managed this appropriately.
64. There was another dietitian assessment on 20 June, this contained all the information that would be expected, the review was carried out appropriately and a plan put in place.
65. There is also evidence the dietitian team listened to Mrs H’s needs during this assessment, and took on board her views.
66. Further reviews were held on 24 and 26 June. These assessments were carried out appropriately, with the correct information included.
67. On 4 July it was noted Mrs H may be discharged home, and the nutrition team were contacted to review her. This took place on 5 July, and the dietitian considered Mrs H’s concern of being discharged home with an NJ tube and that she and her family were unlikely to manage with NJ feeding at home. They made an appropriate plan which was trialled within the hospital by trying oral nutritional supplements.
68. This is in line with NICE nutrition support in allowing a patient to transition from NJ feeding to oral nutritional supplements. This is clearly documented in the medical records and the decision making is clear.
69. On 8 July, the dietitian noted in the medical records that the trial of nutritional supplements was not well tolerated, and NJ feeding within the hospital was the best option. It also took on board Mrs H’s view on this. NICE nutrition support guidelines states that NJ feeding should be considered, if oral feeding is not well tolerated. The plan to go back to NJ feeding, was therefore in line with this.
70. There were also further dietitian assessments on 12, 15 and 19 July which were all appropriate and involved Mrs H in the plan going forward. The latter assessment advised an increase of feed rate to allow a bigger gap between feed stopping and starting. This is common clinical practice to encourage oral intake, to try and increase appetite whilst on a feed.
71. A further dietitian assessment on 22 July, reiterated the challenges of discharging Mrs L with an NJ tube (as per her wishes), as her family were unable to manage this at home, and oral nutritional supplements trials were not successful.
72. We can see evidence from the medical records, that overall, during the dietitian assessments held between June and August, the team listened to Mrs H’s needs, discussed the nutrition plan and involved her in this. This is in line with HCPC standards.
73. In summary, the nutrition team throughout Mrs H’s care, appear to have provided adequate care that is in line with NICE nutrition support guidance and HCPC standards.
Total parenteral nutrition
74. We understand Mrs L’s concern about failings in TPN.
75. TPN is provided when all other methods of feeding are not suitable, usually due to the digestive tract being non-functional or inaccessible. NICE nutrition support guidance states that TPN should be considered in those at risk of malnutrition and have an inadequate or unsafe oral/enteral nutritional intake. It is the highest tier of nutritional support and should not be considered unless other options are deemed unsafe. These decisions should be made alongside professionals with an understanding of nutrition and the relevant skills and training to provide nutritional support.
76. The medical records initially advised TPN on 15 June and as explained above, a dietitian review was requested. We cannot see justification within the medical records, about why TPN was recommended, however we have still been able to consider if this was appropriate. Once Mrs H was referred to the nutritional team, a decision was made to start NJ feeding.
77. We note the medical team were thinking of starting TPN, but after further review, NJ feeding was recommended and started. We think this was the correct decision as there was no evidence that Mrs L had an unsafe or inadequate digestive function. Oral nutritional supplements were also trialled during the admission, but this was not successful, so NJ feeding was the best option.
78. We understand Mrs L’s concern that due to Mrs H’s inability to tolerate any oral nutrition and vomiting with oral attempts, that TPN was justified. An NJ tube is used when someone cannot tolerate feeding into their stomach, such as due to persistent vomiting. The NJ tube allows for direct delivery of nutrition into part of the small intestine and bypasses the stomach, reducing feeding-related complications like vomiting. We therefore think it was reasonable for NJ feeding to be provided to Mrs H, over TPN.
Incorrect and unsuitable foods administered
79. Mrs L complains that incorrect foods were given to Mrs H in the rehabilitation hospital. As highlighted above, the NMC code outlines that nurses should make sure the fundamentals of care are effectively delivered and this includes nutrition.
80. We reviewed the enteral feeding regimens (individualised plans for delivering nutrients directly into the gastrointestinal tract, via a tube).
81. These appear to be well written and clear, while ensuring the plans in place met Mrs H’s requirements.
82. Mrs H had a professional assessment around nutrition, and there is nothing to indicate anything went wrong here. It appears the nutrition plan and recommendations were followed, to give Mrs H soft food and snacks (when tolerated).
83. There are also many food record charts which detail the foods offered throughout the admission. The evidence indicates the correct foods, and nutritional supplements were provided to Mrs H during this time.
84. Aspiration pneumonia can occur when food is inhaled into the lungs, but there is nothing to suggest that this was caused by the wrong foods being given to Mrs H.
Rehabilitation hospital
85. On Mrs H’s transfer to the rehabilitation hospital on 3 August, Mrs L says staff failed to send any nutrition and sterile water for the NJ tube. She also says staff were not trained to use the NJ tube. We recognise this was a worrying time for Mrs L.
86. NICE nutrition support guidance states that the management of tubes, such as NJ tubes, should be done by people with relevant knowledge and training.
87. Within the handover to the rehabilitation hospital, Mrs L’s NJ tube was still in place and the feed rate was handed over. At this time, she was also encouraged to continue to try a soft diet and snacks.
88. A dietitian reviewed Mrs H prior to her transfer and provided a handover to staff at the rehabilitation hospital, this was done in writing and verbally. The Trust explained to us, that the dietitian arranged for feed to be transferred to the rehabilitation hospital, along with two types of feeding regimes if required and ward staff should have had access to sterile water. We think this was appropriate.
89. The evidence from the medical records shows that Mrs H did not arrive with feed at the rehabilitation hospital and staff there, were unsure how to manage the NJ tube, so were not able to start it.
90. As staff at the rehabilitation hospital were unsure how to manage the NJ tube, this was not used, and Mrs H was left without feed. This is not in line with nutrition support guidance and means a failing in Mrs H’s care occurred.
Impact
91. We have found that staff at the rehabilitation hospital were unsure how to use the NJ tube and this resulted in staff not providing any feed to Mrs H, for two days.
92. We think this was likely to have been distressing for Mrs H and may have led to her feeling hungry. However, this is unlikely to have had a long-term significant impact on her weight, or health. Intravenous (IV – directly through a vein) fluids were also provided during this time, so Mrs H did not become dehydrated. We recognise the impact this had on Mrs L and the worry and distress she felt witnessing this.
93. On 5 August, a dietitian review advised the NJ tube could start to be used and for feed to be resumed at a reduced rate initially and then increased to the previous rate, after 24 hours if tolerated. We hope this provides some reassurance to Mrs L that the correct actions were taken later, despite the initial delay.
94. We have made some recommendations at the end of this report for the Trust to put things right in relation to the failing we have identified here.
Medications administered via the NJ tube 95. Mrs L says staff administered medications down the NJ tube which resulted in blockages.
96. We reviewed this issue with our pharmacist adviser.
97. NEWT guidelines give an indication of whether a drug can be given down an NJ tube, or not. In some cases, there is guidance given in terms of crushing tablets and volumes of water to mix the tablets. For other drugs, no clear guidance exists however, that does not mean that the medicine cannot be administered down the NJ tube, but there is a lack of evidence.
98. The key to using the NJ tube for drug administration is to ensure that the tablets are very well crushed and therefore have a small particle size.
99. The inpatient drug charts indicate that medicines were administered to Mrs H orally or through the NJ tube. There are some references in the nursing records that indicate on occasions, the NJ route was used for drug administration.
100. Given Mrs H’s medical condition and issues with oral intake, it appears reasonable that the NJ route was used for drug administration.
101. We can see that Mrs H’s NJ tube became blocked twice on 11 August and 22 August and this was resolved through attendance to the hospital. The evidence does not tell us if the tablets were crushed appropriately or not, prior to these attendances, so unfortunately, we cannot reach a view on this. However, having the tube unavailable for short periods of time, would not have had any lasting consequences for Mrs H.
102. We think the use of the NJ tube for administering Mrs H’s medication was reasonable, given the issues she had with oral intake.
Communication 103. Mrs L says the medical team did not provide updates and there was a lack of communication about Mrs H’s care during her inpatient stay.
104. The Trust said the medical notes are well detailed and there is evidence of good communication between the different medical teams, including the on-call surgical team, as well as with the family. It did not identify any issues with communication with Mrs L or her family.
105. GMC good medical practice, says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
106. To consider this issue we took an overall view of the communication with Mrs L during the hospital admissions.
107. Throughout the admissions, there are regular documented discussions in the medical records with Mrs H’s family. This includes regular updates about Mrs H’s prognosis and treatment going forward. We also note the medical team held several conversations with Mrs L to provide updates and answered questions appropriately, including responding to concerns she raised via email during Mrs H’s admission.
108. We understand Mrs H’s concern that the medical team could have done more to communicate with the family. We would not expect every test result to be shared, unless this was significant and caused a change in treatment/prognosis. We think the evidence shows the medical team provided reasonable updates to Mrs L about Mrs H’s care.
Discharge 109. Mrs L complains the Trust inappropriately discharged Mrs H twice in August 2022. On 3 August, she says she was discharged to the rehabilitation hospital when she was not medically fit and had issues with the NJ tube. And on 9 August, she said she was discharged from the rehabilitation hospital, when she had coffee ground vomit and a rectal bleed. We are sorry to hear of Mrs L’s concerns and understand she was worried at this time.
110. In its complaint response, the Trust said that while Mrs H was waiting for surgery, it wanted to find a safe place for her to continue her NJ feed until then, due to the risk of further infections in hospital. She was transferred to the rehabilitation hospital on 3 August after she was deemed surgically fit for discharge and awaiting assessment. She was discharged from there on 9 August, into a care home with plans to await surgery on 2 September.
111. The Trust also said it was appropriate to discharge Mrs H with the NJ tube, and it is not uncommon for this to happen for an ongoing period to ensure nutritional needs can be met.
112. We considered this issue with help from our physician and dietitian advisers.
113. GMC good medical practice says doctors should assess a patient’s condition and promptly arrange suitable advice, investigations or treatment where necessary. It says they should also consult colleagues where appropriate.
114. The medical team reviewed Mrs H prior to her discharge on 3 August. The medical records note that her observations indicated she was well enough to be transferred for rehabilitation while waiting for surgery. This was an appropriate decision while she was waiting for surgery, due to the infection risks within an acute hospital.
115. Mrs H was stable and there was no indication there was any issue with her NJ tube on discharge. It was able to provide ongoing and adequate nutrition for Mrs H and this was evidenced by her ongoing weight gain.
116. On transfer to the rehabilitation hospital, Mrs H’s family were not able to support NJ feeding and other methods of feeding, such as oral nutritional supplementation, were not successful. She was medically fit to be discharged to a rehabilitation hospital where she could still be cared for, and her NJ feeding supported.
117. On 5 August, while at the rehabilitation hospital, it is noted in the medical records that Mrs H may have had coffee ground vomiting. Coffee ground vomiting was not mentioned again during this admission, or prior to her discharge from the rehabilitation hospital on 9 August.
118. In June, Mrs H had investigations that showed she had a hiatus hernia. The vomiting appeared to have been caused by this, and Mrs H was already waiting for surgery to treat this.
119. The medical team were also treating her with IV omeprazole, that is a proton pump inhibitor and works by reducing the amount of acid produced in the stomach, which can help with gastric bleeding. Her haemoglobin (a protein in red blood cells that carries oxygen) also did not drop, indicating there was no significant blood loss at this time. Therefore, there was not a definite indication for a further gastroscopy, or any further investigation or treatment.
120. Vomiting was also not present when Mrs H was readmitted to the Trust on 11 August, to have her NJ tube unblocked.
121. On 8 August, the medical team reviewed Mrs H, and it was noted she had a rectal bleed. This was thought to be from having constipation, possibly caused by haemorrhoids. This is a common cause of bleeding and would not usually be considered to be dangerous or require someone to remain in hospital.
122. The observations at the time do not indicate that she had lost a significant amount of blood (she was not tachycardic where the heart rate is faster than a hundred beats per minute, which is usually an initial indicator of significant acute blood loss).
123. The evidence tells us she was medically fit to be discharged to the care home at this point, while awaiting surgery.
124. The discharge was well planned with involvement from the dietitian team and no concerns were raised about the NJ tube.
125. When Mrs H was readmitted to the Trust on 23 August, she was vomiting blood and had pain in her stomach. This does not appear to be related to her being discharged too soon, as it was not related to the bleeding concern prior to the earlier discharge. A later discharge is unlikely to have prevented this readmission.
126. The evidence shows that for both discharges in August, Mrs H was stable and there were no issues with the NJ tube, which meant she had to be kept in hospital. The decision to discharge her was therefore in keeping with GMC good medical practice guidelines.
Pain management and nursing care Pain management
127. Mrs L says the Trust did not manage Mrs H’s pain properly at the end of her life and her personal care was poor. We recognise this was a distressing time for Mrs L.
128. The NMC code says nurses should accurately identify, observe and assess signs of normal or worsening physical health in a person receiving care and make a timely referral to another practitioner when any action is required. It also says they should ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of their competence.
129. The NMC code also states that nurses should take appropriate action to reduce or minimise pain or discomfort.
130. NICE care of dying adults states that doctors should decide on the most effective route for administering medicines in the last days of life, tailored to the dying person’s condition, their ability to swallow safely and their preferences. It also says they should consider prescribing different routes of administering medicine if the dying person is unable to take or tolerate oral medicines.
131. Mrs H was admitted to the Trust’s ED on 23 August via the care home. She had a medical review at 3.10pm, which documented she had vomiting and generalised abdominal pain, which had settled. She was given paracetamol and this was appropriate.
132. Mrs H was moved to an inpatient ward on 24 August at 3.30am. The medical records document she was alert, and able to voice her needs, her call bell was in reach, and she was using a bedpan to pass urine. Her pain was scored as 1, which meant it was mild. Nursing staff requested a medical review due to the ongoing vomiting and low blood pressure. This is in line with the NMC code.
133. At this stage, Mrs H was very unwell, and her family were called at 11am. There is no indication that she was in uncontrolled pain and the main symptom was vomiting. Nursing staff escalated to the medical team as indicated and at 12.15pm, it is documented Mrs H was alert and orientated, she was unwell but there was no documented pain.
134. At 12.35pm, nursing staff escalated Mrs H’s care to the critical care outreach team, as she was unresponsive. Pain was not a problem, but she did report epigastric tenderness (stomach-ache) which was likely related to vomiting, and this was addressed using a Ryles tube (a flexible tube inserted through the nose, and this makes it more comfortable for a patient with continuous vomiting).
135. It was documented that Mrs H made no complaints of pain and was comfortable with pain scores of 0 (indicates no pain) given throughout 23 and 24 August. At 9.30pm, the nursing staff called the medical team for stronger analgesia, and she was reviewed in the early hours of 25 August.
136. The medical team reviewed Mrs H, and she was given morphine through a syringe driver (delivers medication continuously under the skin), with top up pain relief if she required it. This was appropriate pain relief to give Mrs H at the end of her life to control symptoms and keep her comfortable. It was also given via an appropriate route due to the issues Mrs H had with oral intake and vomiting.
137. In summary, the nursing team monitored Mrs H’s pain, and it was managed appropriately by the medical team in line with NICE care of dying adults guidance.
Nursing care
138. Mrs L also complains that during this admission, Mrs H was left in her own blood, faeces and urine, causing a lack of dignity.
139. The NMC code states that nurses must deliver the fundamentals of care effectively and this includes bladder and bowel care and making sure that those receiving care are kept in clean and hygienic conditions.
140. Mrs H was admitted to the inpatient ward on 24 August. At this point, she was able to use a bedpan to pass urine. A urinary catheter was then inserted at 12pm, and there is no evidence in the medical records that Mrs H was left lying in her own urine.
141. The main concern was ongoing vomiting, and this was escalated to the medical team and on the same day, a Ryles tube was inserted. Vomit from this tube is contained in a bag. This was removed at 8.45pm on 25 August, at her family’s request. This indicates that Mrs H was not left lying in her own vomit and this was contained within the bag, while the tube was inserted.
142. The NMC code also says nurses should observe and assess the need for intervention for people, families and carers. They should also identify, assess and respond appropriately to uncontrolled symptoms and signs of distress including pain, nausea, thirst, constipation, agitation, anxiety and depression.
143. Mrs H’s family indicated they wanted to be involved in general care on 25 August and it is documented in the medical records that ‘adequate private time’ was given for the family to be with Mrs H, and they were advised to let the nurses know if there were any concerns. There was no reference to faecal incontinence at this time.
144. In summary, the medical records show evidence that the nurses attended to Mrs H’s personal care at the end of her life. A Ryles tubes managed any vomiting, and a urinary catheter managed her urine output. Her family indicated that they wanted to be involved in general care at the end of life, they were given private time but with clearly documented advice to call for nursing staff should support be needed. These actions are in line with the NMC code highlighted above.
145. We acknowledge that Mrs L has provided images of blood-stained sheets. Nursing staff were trying to control the bleeding by inserting the Ryles tube, but it does appear that some blood did go on Mrs H’s bedsheets. We do not think this was a failing in care due to the actions taken above, but we are sorry to hear this occurred and recognise the upset it caused.
Complaint handling 146. Mrs L also complains the Trust handled her complaint poorly, as it did not provide a response to the further complaint letter she sent in December 2022, and did not provide regular updates to her about progress.
147. Our complaint standards say complaints staff should respond to complaints at the earliest opportunity and give clear timeframes for how long it will take to look into the issues, taking into account the complexity of the matter. It also says staff should provide regular updates as agreed with the parties, throughout.
148. Mrs L initially raised her complaint with the Trust in August 2022, and it provided its initial response in October. She responded to this on 20 December after she reviewed Mrs H’s medical records, with further issues and questions. The Trust acknowledged receipt of this via email on 21 December and said that it would review the further issues and provide a response in due course.
149. Mrs L contacted the Trust in January 2023 to chase this and in February, her MP followed this up. The Trust responded to Mrs L’s MP in March 2023. This explained that the complaints department was going through a period of reduced staffing meaning it was not possible to respond to complainants as it would wish. It said that further temporary staffing had been appointed specifically to answer complainants such as Mrs L, who had raised further concerns following receipt of the Trust’s initial response. It explained there were several complainants awaiting a response, with some waiting longer than Mrs L, so concerns would be managed equitably. At this time, the Trust offered its apologies.
150. Mrs L first contacted us in March 2023 as she had still not received a further response from the Trust. At this time, we advised her to wait six months for a response.
151. She contacted us again in June, as she had still not received a response. We contacted the Trust, who advised us it was planning on carrying out a clinical review and this was unfortunately delayed due to strike action and staff availability, but a meeting was planned to go through this. It said it would inform Mrs L and update her again by 4 July.
152. We contacted the Trust again when no update was provided. It informed us that it had experienced delays in setting up the clinical review and it was unable to confirm a date when it would be completed but discussions were taking place about this. It said it would update Mrs L. We advised Mrs L to contact us again if she heard nothing from the Trust by the end of August.
153. The Trust did not provide an update, so we contacted it again in September to enquire about the further response.
154. The same month, the Trust wrote again to Mrs L’s MP. It explained that Mrs L’s complaint was extensive and complex, and it had been unable to complete a clinical review of the episode of care or provide a further response. It said the complaints team had taken additional measures to ensure a response could be provided as soon as possible.
155. In October, the Trust explained to us that it was working to address the outstanding issues and hoped to be able to provide a response shortly. We sent an intervention letter to the Trust in October and explained that if it was not able to provide a further response to Mrs L by 20 December 2023, we would consider if we needed to carry out an investigation into her complaint. We received no response, so considered Mrs L’s complaint further.
156. In May 2024, the Trust advised us that it was looking into Mrs L’s further concerns and it had employed a new complaints officer who was focusing on the complaints that required a further response. It said it aimed to provide a response to Mrs L by 13 June 2024. We told Mrs L that she should wait for the further response, as the Trust had now set a deadline for completion.
157. The Trust was unable to meet this deadline and explained that it was awaiting staff statements and hoped to get the response to Mrs L as soon as possible. Due to the ongoing delays Mrs L had already experienced, in June, we decided to consider her complaint again to decide if we should carry out a detailed investigation. We explained to the Trust that if it did provide a further response to Mrs L in the meantime, we would still consider this as part of our work.
158. Mrs L did not receive a further response from the Trust, and in August we confirmed our detailed investigation about the Trust.
159. On 19 November, the Trust wrote to Mrs L to apologise for the delay in providing a response to her further complaint letter. It explained it had not been able to provide a response due to the level of review required and availability of staff. It also explained that as we were reviewing Mrs L’s complaint, it would close the complaint it had. It apologised to Mrs L for this and any distress it may have caused.
160. In summary, Mrs L sent her further complaint to the Trust in December 2022, and it informed her in November 2024, that it would not be providing a response. This is a delay of 23 months, during which time Mrs L was actively chasing the progress of her complaint.
161. The Trust acknowledged Mrs L’s further complaint letter, but any further updates that it sent to her about this was because either she, her MP or we, made enquiries and asked for an update.
162. We recognise that Mrs L’s complaint was detailed and covered numerous issues, and that this type of further investigation is likely to take more time to complete. We also acknowledge the staffing issues that impacted on the complaints department’s ability to do this, which contributed to the delays in the further investigation.
163. In line with our complaint standards, we would expect the Trust to provide regular updates to Mrs L, explaining the reasons for any delays that occurred and setting a realistic timeframe for a further response. If the Trust could not provide a further response to Mrs L, it should have explained this to her earlier, with the reasons why. It did not do this until we decided to carry out a detailed investigation into her complaint.
164. The evidence shows there were long delays in the Trust’s handling of Mrs L’s further complaint letter, it was not proactive in providing regular updates to her, missed the deadlines it set and did not provide a further response to the additional concerns she raised. This is not in line with our complaint standards and shows a failing occurred in the Trust’s handling of Mrs L’s complaint.
Impact
165. We have identified long delays in the Trust’s handling of Mrs L’s further complaint letter.
166. Mrs L had to take action to find out what was happening with her complaint and contact her MP, and us, to help her do to this. We think this added to the distress Mrs L already felt due to the events complaints about, as well as uncertainty as she did not receive a response to the outstanding concerns she raised. We acknowledge the upset this caused and the impact it also had on Mrs L’s ability to fully grieve, as she was missing explanations about Mrs H’s care.
167. We acknowledge the apology letter the Trust sent to Mrs L in November 2024 regarding the delay in the handling of the complaint, but we do not consider this provides an apology for the full impact this failing had. We have made some recommendations below, for the Trust to address this failing.