Admission:
19. Mr U had two fractures in his right arm following his fall at home on 26 December. Mrs U says the Trust should have discharged her husband home on 28 December when it had decided surgery was not necessary to treat the fractures. The Trust explain the preference is always for patients to be discharged promptly, but only when it is safe to do so.
20. Our physician adviser explains there are no specific guidelines covering what should have happened in this specific scenario and it is often a matter of clinical judgement. GMC Good Medical Practice guidance sets out there is a general duty to provide a good standard of practice and care (paragraph 15). NMC Guidance ‘the code’ says nursing professionals should ‘act in the best interests of people at all times’ (paragraph 14).
21. Mr U transferred from the emergency department (ED) to the orthopaedic ward on 27 December 2021 for further review of his fractures. When clinicians decided it would be better to manage these without an operation on 28 December, our physician adviser explains it was still necessary to ensure he was safe to be discharged from a mobility perspective. Two fractures of the arm would be very painful and immobilising. It was therefore necessary for the OTs to check Mr U was able to get himself around and safely do all his activities of daily living, such as toilet and bathing.
22. Before Mr U was able to see the therapy team to assess his mobility, he had an episode of a fast, irregular heart rate (atrial flutter), which led to concerns over a possible chest infection or blood clot on the lung. Our physician adviser tells us it would have been unsafe to discharge Mr U home at this point, until the clinical concerns had been addressed.
23. We understand Mrs U believes her husband should have been discharged on 28 December and we are sorry to hear about the additional upset this caused. Given Mr U’s clinical condition and the consequent difficulties in assessing his mobility, we consider clinicians acted in Mr U’s best interests and in line with GMC guidance in deciding to keep him in hospital for further review on 28 December. We do not consider there is evidence of a failing here.
Review by senior doctors/ transfer to medical ward:
24. Mrs U says there was a lack of input from senior doctors during her husband’s hospital admission and he should have been transferred to a medical ward. The Trust acknowledge Mr U did not receive regular multidisciplinary senior/ consultant level reviews during his admission. It explains the Trust was at the peak of a Covid-19 wave at this time, which impacted staffing levels affecting continuity of cover, patient flow and availability of beds.
25. NHS Seven Day Services Clinical Standards state ‘once a clear pathway of care has been established, patients should be reviewed by a consultant at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway’. We are aware it is very challenging for hospitals to achieve this for all acute inpatients, given the competing demands on consultant time.
26. There are no specific guidelines around when a patient should transfer from one service to another. Paragraph 15c of GMC guidance says doctors should ‘refer a patient to another practitioner when this serves the patient’s needs’.
27. From the records we can see a consultant did not review Mr U each day of his admission, which should have happened according to the NHS standard in place at this time. Mr U had multiple episodes during his admission where the MET (medical emergency team) were called because he was seriously unwell. Although we appreciate the NHS standard is not always realistically achievable, our physician adviser highlights there was an overall lack of senior clinical input during Mr U’s admission, especially given how unwell he was.
28. Our physician adviser tells us the complexity of Mr U’s medical situation and resultant number of acute episodes of deterioration during his admission was concerning. Given there are no specific guidelines about when to transfer a patient to a different service, our physician adviser explains the decision on whether to transfer to a medical ward would be a clinical judgement decision, depending on the assessment and balance of the patient’s needs, as per GMC guidelines. Mr U’s needs were predominantly medical from 30 December 2021 onwards, and therefore it would have served his needs for clinicians to have transferred him to a medical ward for further management at this point. We consider this is a failing and will explore the impact of this further in respect of specific aspects of Mr U’s care in the sections below.
ICU:
29. Mrs U says clinicians should have transferred her husband to ICU sooner.
30. The UK Intensive Care Society guidelines set out criteria patients should meet to be considered for escalated levels of care. The levels of care are:
• Ward care (needs can be met through normal ward care) • Level one- enhanced care (requiring more detailed observations/ requiring ongoing interventions from critical care outreach teams) • Level two- critical care (increased levels of observations/ requiring interventions to prevent deterioration beyond that of level one). This includes:
• Patients requiring increased levels of observations or interventions (beyond level 1) including basic support for two or more organ systems and those ‘stepping down’ from higher levels of care.
• Patients requiring interventions to prevent further deterioration or rehabilitation needs, beyond that of level 1.
• Patients needing two or more basic organ system monitoring and support.
• Patients needing one organ systems monitored and supported at an advanced level (other than advanced respiratory support).
• Patients needing long term advanced respiratory support.
• Patients who require Level 1 care for organ support but who require enhanced nursing for other reasons, maintaining their safety if severely agitated.
• Patients needing extended post-operative care, outside that which can be provided in enhanced care units: extended postoperative observation is required either because of the nature of the procedure and/or the patient’s condition and co-morbidities.
• Patients with major uncorrected physiological abnormalities, whose care needs cannot be met elsewhere.
• Patients requiring nursing and therapies input more frequently than available in level 1 areas • Level three- critical care (needing advanced respiratory monitoring and support)
31. The ICU reviewed Mr U on 4 January and decided he was not suitable for critical care at that point, and it was safe for his care to remain on the ward. We cannot see the treating clinicians requested a further review from ICU for a possible transfer after this until 19 January, when his condition had worsened considerably following a fall.
32. Our physician adviser says this would be a ‘borderline’ case where there was no ‘hard’ indication for escalation of Mr U to level two or three critical care. As per the UK intensive care guidelines above, every decision is individualised. Given Mr U had co-existing medical problems and his condition was deteriorating, our physician adviser says there could be an argument for escalation of Mr U’s level of care earlier in the admission. However, given it is borderline over whether Mr U met the criteria for level two or three critical care, we cannot say it was a failing that he was not transferred sooner.
Oedema/ fluid balance
33. Mrs U says the Trust did not appropriately manage her husband’s oedema. Oedema is a build-up of fluid in the body causing swelling. It can be caused by several factors including taking certain medications, standing or sitting in the same position for too long, an injury, or problems with the kidneys, liver or heart.
34. The Trust says Mr U’s oedema was not resolved due to his low albumin (protein made by the liver), immobility and renal failure.
35. The NICE guidance on intravenous fluid therapy in adults in hospital says:
‘.2.2 Assess the patient's likely fluid and electrolyte needs from their history, clinical examination, current medications, clinical monitoring and laboratory investigations:
• history should include any previous limited intake, thirst, the quantity and composition of abnormal losses, and any comorbidities, including patients who are malnourished and at risk of refeeding syndrome • clinical examination should include an assessment of the patient's fluid status, including: － pulse, blood pressure, capillary refill and jugular venous pressure － presence of pulmonary or peripheral oedema － presence of postural hypotension’.
• All patients continuing to receive IV fluids need regular monitoring. This should initially include at least daily reassessments of clinical fluid status, laboratory values (urea, creatinine and electrolytes) and fluid balance charts, along with weight measurement twice weekly
36. When a patient who is unwell has low blood pressure (as in Mr U’s case) there is often a need to give intravenous fluid to rehydrate them. When someone is unwell, their blood vessels also often become 'leaky', with some fluid moving out of the blood vessels, into the tissues, causing swelling. There is therefore a difficult balancing act between giving sufficient intravenous fluids to rehydrate, without giving too much to cause fluid overload and. Fluid overload can raise blood pressure, causing swelling (oedema) and impact organ function. This balance is even more complex in patients with advanced kidney failure such as Mr U.
37. Clinicians assessed Mr U's fluid status on admission. The clinical examination showed the presence of oedema, and the doctor assessed for other signs Mr U was overloaded with fluid. From the notes, it appears the orthopaedic doctors gave Mr U fluids conservatively during his admission, and were likely concerned about avoiding fluid overload, when his blood test results suggest he was actually dehydrated.
38. We can see the fluid balance assessments were made without specialist input from senior medical clinicians. The notes show factors set out in the NICE guidance such as postural drop in blood pressure, capillary refill time, moist/dry status of his mucous membranes, the presence or absence of oedema, and Mr U’s perception of thirst were not assessed and documented as frequently and comprehensively as they should have been, in line with the guidance. Our physician adviser tells us senior clinicians would likely have had a better understanding that it was appropriate to give intravenous fluids to a dehydrated patient who also has kidney failure, if it is required. There would have most likely been daily review of the charting of his fluid intake and output on a medical ward. This would have given a better appreciation of his fluid status (i.e. was he passing more urine than taking in fluid). There would have been more expertise in assessing Mr U’s fluid status at the bedside and whether there were signs he was dehydrated, so this could have been identified and potentially treated sooner.
39. We consider there was a failure to carry out appropriate assessments to assess Mr U’s fluid status in line with NICE guidelines. There were very finely balanced decisions about Mr U’s fluid requirements which would have benefitted from the expertise of senior medical input. We will consider the impact of this below.
Abnormal Heart Rhythm:
40. Mrs U says the Trust failed to appropriately manage her husband’s atrial flutter (irregular heartbeat). The Trust says Mr U’s fast heartbeat was resolved intermittently between MET calls and in the presence of infection, pulse rates often rise.
41. Paragraph 15 of GMC guidance says ‘you must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must… adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient’.
42. With atrial flutter, the top two chambers of the heart (the atria) do not contract as they should, and blood clots can potentially form in the heart. If blood clots form, and then travel to the brain, this can cause a stroke. Our physician adviser explains ordinarily when a patient has atrial flutter, doctors should consider anticoagulation (medication to prevent clots from forming or getting bigger) to reduce the risk of stroke, but they also have to balance this with the risk of bleeding. The NICE Guidelines on atrial fibrillation indicate the use of the CHADS2VASC and ORBIT scores to assess the relative risks of blood clots due to atrial flutter causing a stroke, versus the risk of bleeding (paragraph 1.2.1). These scores help guide clinicians’ decisions on anticoagulation treatment and monitoring.
43. When clinicians identified Mr U's atrial flutter on 30 December, there was a comprehensive review to identify and treat any reversible causes. The notes show this included looking for abnormalities in the salt levels in Mr U’s blood, ensuring he was well hydrated, checking his thyroid function, checking for problems with the structure or function of his heart and looking for infection. This was in line with GMC guidelines on providing good clinical care.
44. Clinicians gave Mr U bisoprolol on 30 December. Bisoprolol is a beta blocker medication which is generally a first line treatment for atrial flutter. A medical registrar noted on 7 January they ‘will need to consider anticoag[ulants] when [Mr U] is more stable’. There are no other notes to show clinicians considered anticoagulation again. Mr U was on a very low dose of heparin (a type of anticoagulant) to help prevent blood clots on his leg or lungs while he was in hospital, but our physician adviser says this would not be sufficient to prevent a clot forming with atrial flutter.
45. Our physician adviser tells us, the best treatment a situation like this is not always clear and comes down to fine balance of risks versus benefits, and it would also depend on the patient’s views. Not giving anticoagulants increases the possibility of a big stroke that could cause a disability or result in death. Conversely, giving anticoagulants could increase the risk of bleeding which could also cause death if it was a bleed into the brain or a massive bleed from the stomach or bowel. Decisions about managing atrial flutter and prescribing anticoagulants, and/ or other medications to bring Mr U’s heart rate down are complex and outside the remit of the orthopaedic team to manage. Senior medical input should have been sought at this point.
46. Mr U’s CHADS2VASC score was 3, indicating he had a moderate to high risk of a stroke or other blood clot from atrial flutter. His ORBIT score was 4, which indicates he also had a high risk of bleeding. This shows that whilst anticoagulation was indicated to reduce the risk of stroke or systemic embolisation (blood clots going elsewhere in the body such as the bowel), this would be associated with an increased risk of bleeding.
47. Our physician adviser tells us it is possible after considering all these factors and risks, the medical team might have opted not to give Mr U anticoagulants in the short term, but they should have fully considered this and documented with the risks and benefits of each course of action outlined, which did not happen here.
48. The notes show Mr U had an ‘intra- abdominal catastrophe’ which led to the peritonitis and his eventual sad death. Establishing the cause of an ‘intra-abdominal catastrophe’ is challenging, and without a post-mortem examination or a CT scan, is only ever presumptive. Mr U did not have any particular risk factor for a perforated bowel, but did have atrial flutter which is a risk factor for ischaemic bowel. In the same way as blood clots can form and travel to the brain causing a stroke, blood clots can also travel to other parts of the body such as the bowel. This can result in the artery being blocked, causing the organ to be starved of blood/oxygen and essentially die. This can come on suddenly and can lead to sepsis/ septic shock.
49. We cannot definitively say what caused Mr U’s intra-abdominal catastrophe, leading to acute peritonitis, septic shock and his death given the lack of imaging and postmortem. Our physician adviser tells us given Mr U’s risk of ischemic bowel from uncontrolled atrial flutter, this was a more likely cause than perforation, but we could not say for certain. Initiating full anticoagulation earlier in the admission could have potentially prevented a blood clot forming and then subsequently leading to the ischaemic bowel. This is, however, complicated by the risk of bleeding and the delicate balance of the risks.
50. We consider there was a missed opportunity for clinicians to fully consider and weigh up the risks and benefits of treating Mr U’s atrial flutter with anticoagulation. We will further consider the impact of this below.
Antibiotics/ inflammatory markers:
51. Mrs U says clinicians repeatedly stopped her husband’s antibiotics, so his infection was never under control, and they did not escalate/ treat her husband’s high C-reactive protein (CRP). CRP is a protein produced by the liver. A high level of CRP in the blood is a marker of inflammation, which can be caused by a wide variety of conditions including infection.
52. Paragraph 15 of GMC Good Medical Practice Guidance says doctors should ‘provide effective treatments based on the best available evidence’.
53. The Trust antimicrobial guidelines say teicoplanin is an option to treat cellulitis in the case of severe penicillin allergy. It also says levofloxacin can be given to treat pneumonia in patients with penicillin allergy, such as Mr U.
54. On 2 January, clinicians diagnosed Mr U with cellulitis, which is an infection of the deeper layers of skin and underlying tissue. They prescribed teicoplanin, which is an antibiotic generally used to treat infections caused by bacteria that affect the skin and soft tissues. The notes show clinicians administered teicoplanin on 2-4, 8, 10, 13, 16 and 19 January. When Mr U had developed pneumonia later during his admission, clinicians prescribed other antibiotics (gentamicin and levofloxacin).
55. During the ward round on 6 January 2022, Mr U’s CRP was noted as 224 from the previous day. This was high and well outside the normal range. The clinician noted on examination; Mr U had an extremely swollen arm. The plan was to repeat the CRP test and ‘evaluate for other sources of infection’. Later that day there was a MET call for Mr U as he was unconscious due to an opioid toxicity. At that point clinicians requested a chest X-ray, which did not show any signs of infection.
56. Our physician adviser tells us the Trust’s plan to monitor Mr U’s inflammatory markers was appropriate and we consider it was in line with GMC guidance on providing good clinical care. It is possible Mr U’s persistently high CRP was a result of a severe infection that was taking time to settle.
57. The prescription of teicoplanin for Mr U’s cellulitis was in line with local prescribing guidance. The required dose of teicoplanin is affected by a patient’s renal function. At Mr U’s low level of renal function, our physician adviser explains this could mean dosing only every three days, as the medication lasts in the body much longer. This is also the case for gentamicin, where there may be several days between doses at Mr U’s degree of renal function.
58. Our adviser says there is evidence of good involvement of the pharmacy team in the management of Mr U’s medications. We consider clinicians prescribed and administered antibiotics in line with local prescribing guidelines and there was appropriate consideration of his level of renal function and we not seen evidence of a failing.
Pain management/ opioid toxicity:
59. Mrs U says clinicians failed to manage her husband’s pain and gave him an toxicity of oxycodone (Oxycontin) on 6 January which caused opioid toxicity. It is an opiate painkiller, and it is used to treat severe pain. Morphine and fentanyl are other types of opioid painkiller. Opioid toxicity happens when patient has Ur quantities of opiates than they can physically tolerate. This can lead to drowsiness, respiratory depression (slow or shallow breathing) and confusion. Naloxone is a medication used to reverse the effects of the toxicity.
60. The Trust says pain control was difficult because of Mr U’s renal failure. It says clinicians started opiates at the correct dose and altered it appropriately in response to pain.
61. Paragraph 16 (c) of GMC guidance says doctors should ‘take all possible steps to alleviate pain and distress whether or not a cure may be possible’.
62. The Trust’s pain management guidance does not recommend morphine for patients with chronic kidney disease. The British National Formulary (BNF) morphine section also says morphine should be avoided in patients with renal impairment or the dose should be reduced, as opioid effects are ‘increased and prolonged’.
63. When prescribing and administering opioid medication, clinicians need to consider the level of the patient’s kidney function. Estimated glomerular filtration rate (eGFR) is a calculation of how many millilitres of waste the kidneys should be able to filter in a minute. Healthy kidneys should be able to filter more than 90ml/min. Mr U’s recorded eGFR on admission was 15. The Trust’s pain control guidance recommends prescribing Oxycodone and Fentanyl for patients with an eGFR’s lower than 30 who have moderate to severe pain. For patients with an eGFR between 15-29ml/min the guidance says the starting dose should be 2.5mg. For patients with an eGFR of less than 15ml/min, the starting dose is 1.25mg. Oxycodone is approximately one and a half times stronger than morphine so a 2.5mg dose of oxycodone is roughly equivalent to 3.75 mg of morphine.
64. On admission, Mr U complained of pain in his right arm due to the injuries he sustained in the fall. Clinicians initially prescribed Mr U with morphine to help manage his pain on 27 December and this was regularly administered up until 5 January. Clinicians also prescribed Mr U with paracetamol (1000mg) four times daily on 30 December to help manage his pain.
65. The initial doses of morphine administered on 27 and 29 December were 5mg and this increased to 10mg on 30 December. 10mg doses were then administered on the subsequent days up until 5 January. On 6 January, clinicians changed Mr U’s opioid painkiller and prescribed him with oxycodone. He had a 2.5mg dose at 9:02am and 3:45pm and a 5mg dose at 11:26am.
66. The notes say the oxycodone dose on 6 January made Mr U ‘sleepy’. The MET reviewed him and noted he was not maintaining his own airway and was very drowsy. The impression was opioid toxicity, which was treated with naloxone in ICU. Following the opioid toxicity and administration of naloxone on 7 January, Mr U’s pain score was recorded as four (on a scale of one to four). After oxycodone restarted the following day, Mr U’s pain score was mainly recorded as zero and one, until 15 January when it rose to two at several points in the day. On 17 January it was recorded at four for several hours and two’s and three’s on 18 January.
67. From the notes we can see there were times when Mr U’s regular paracetamol was not administered as prescribed during his admission. The pain team first reviewed Mr U on 11 January; two weeks after he was admitted. They noted the missed doses and recorded they spoke to nursing staff about the importance of giving regular paracetamol. Our physician adviser says these missed doses would have resulted in an increase in pain for Mr U and/or the potential need for more opiate medication. This is not in line with GMC guidance on alleviating pain.
68. We can see the 5 and 10mg doses of morphine administered to Mr U between 27 December and 5 January were significantly over the equivalent dose of oxycodone recommended in the Trust guidelines. Our physician adviser says it was not appropriate or in line with Trust and BNF guidance to give this amount of morphine to a patient with advanced renal failure such as Mr U. This more likely than not led up to his opioid toxicity on 6 January and the necessity to use the naloxone to reverse this.
69. Given the risks of using morphine with patients with renal impairment such as Mr U, we consider oxycodone should have been given from the outset, instead of morphine, as recommended by the pain management guidance. We appreciate Mrs U says the doses of oxycodone on 6 January caused his opioid toxicity. From the evidence we have seen, it appears the excessive doses of morphine in the days leading up to this, materially contributed to the opioid toxicity.
70. Based on the clinical advice and the guidelines referenced above, we consider the Trust failed to provide appropriate pain relief/opioids to Mrs U given his advanced renal failure. This is likely to have resulted in additional pain for Mr U and opioid toxicity. We will consider the impact of this later in this report.
Medications:
71. Mrs U complains about how clinicians managed her husband’s medications during his admission. She says there was a delay in prescribing her husband with his regular Aranesp medication and clinicians continued to give her husband laxatives even though he had diarrhoea. She says this contributed to his overall weakness and deterioration in his clinical condition. The Trust say medications were prescribed and administered appropriately.
72. The NICE clinical knowledge summary on constipation says Movicol and Laxido are commonly used laxatives and are reasonable choices in patients with constipation.
73. Paragraph 16 of GMC guidance says ‘In providing clinical care you must… prescribe drugs or treatment, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs’
74. From the notes we can see a clinician prescribed Mr U with Laxido powder on 30 December to prevent constipation. This prescription was stopped on 11 January. We can see from the nursing notes Mr U reported feeling constipated on 31 December. The nursing notes also say Mr U had ‘loose stools’ on 12 and 13 January and type 7 (diarrhoea) black stools on 14, 15, 16 and 17 January. Clinicians prescribed loperamide hydrochloride which is a medication to relieve diarrhoea on 17 January.
75. On the prescription chart, Laxido was marked as ‘medication not required’ on multiple occasions during the admission and it was not given at all on several days. This indicates nursing staff used their judgement to not administer laxatives when they were not needed because Mr U’s bowels had been opened satisfactorily. Based on the available evidence, we cannot say on the balance of probabilities the laxatives were administered inappropriately.
76. Aranesp is a medication that helps stimulate the body to produce more red blood cells. A hormone called erythropoietin (or 'EPO') is produced by the kidneys and is involved in this process. When patients have kidney failure, less EPO is produced by the kidneys and therefore they can become anaemic and Aranesp is prescribed.
77. On 1 January 2022 the notes say Mr U's wife reported she was concerned about her husband’s haemoglobin level. Haemoglobin is a protein found in red blood cells and low levels can be a symptom of anaemia. Mrs U questioned whether her husband should be having his Aranesp medication. The notes show there was a plan for clinicians to discuss the Aranesp medication with the renal team on 4 January 2022, and a dose was given on 5 January 2022.
78. Our physician adviser explains Aranesp needs to be carefully monitored. If the red blood count is allowed to rise too much, it can increase the risk of having a stroke, a heart attack, a blood clot, cancer recurring, or even death. The renal team had initially withheld it as Mr U’s haemoglobin levels were in normal range at 135. As is common with a fracture (which would involve a degree of bleeding inside the body), Mr U's blood count dropped a little on 31 December 2021 and his haemoglobin was 101.
79. Our physician adviser tells us a few days delay in administering the Aranesp medication would not have had a significant impact on Mr U’s blood count and there are significant risks if it rises too much. We therefore consider it was appropriate for the team to wait to consult with the renal team for advice before administering the Aranesp medication. The inflammation associated with infections can also make the body less responsive treatment to Aranesp. When Mr U’s blood count did not improve there was further discussion with the renal team who made an appropriate decision to increase the frequency of the medication to address this. We consider the treating clinicians considered Mr U’s Aranesp medication, appropriately discussed it with the renal team and administered it appropriately in line with GMC guidance.
Fall on 19 January:
80. Mrs U says her husband fell trying to get out of bed on 19 January when he should have been monitored at all times.
81. The Trust explain it is desirable for patients at risk of falls to be monitored in an observable bed space, with either one-to-one nursing or ‘bay watch’. Bay watch is when a member of staff is stationed in the bay and a tag system is in place if they leave someone else takes over, meaning the bay is not unmanned. The Trust says Mr U was in an observable bed space and the bay had been identified as requiring bay watch. It explains it was experiencing extreme pressures during this period.
82. At the time of Mr U’s fall the Trust explains the nurse in charge was undertaking handover and the remaining nurses on the ward were required to support elsewhere, which meant there was a lapse in the bay watch in the bay that Mr U was nursed in. It explains the hospital was experiencing extreme pressures during this period with a peak in COVID-19 affecting both having to nurse patients in closed bays and staffing levels due to unforeseen absence.
83. NICE Guidance on prevention of falls in older people says:
1.2.2.2 For patients at risk of falling in hospital (see recommendation 1.2.1.2), consider a multifactorial assessment and a multifactorial intervention.
1.2.2.3 Ensure that any multifactorial assessment identifies the patient's individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay. These may include:
• cognitive impairment • continence problems • falls history, including causes and consequences (such as injury and fear of falling) • footwear that is unsuitable or missing • health problems that may increase their risk of falling • medication • postural instability, mobility problems and/or balance problems • syncope syndrome • visual impairment.
1.2.2.4 Ensure that any multifactorial intervention: • promptly addresses the patient's identified individual risk factors for falling in hospital and • takes into account whether the risk factors can be treated, improved or managed during the patient's expected stay.
84. In accordance with the NICE Guidance above, our nursing adviser says Mr U should have had a multifactorial falls risk assessment followed by multi factorial interventions to try to prevent any falls. These interventions include use of bed rails if appropriate and increased level of observation.
85. The notes show nurses started a mobility/risk of falls care plan for Mr U on the day of his admission which indicated he had a high risk of falls. Nurses completed a falls assessment on 28 December and noted he had a history of falls. Nurses also completed a rails assessment for Mr U every other day from 27 December onwards. We can see from the nursing charts; bed rails were intermittently used for Mr U and staff noted he required an increased level of supervision, in the form of a ‘bed buddy’ at all times on 3 January.
86. At 8:10am on 19 January, a clinician noted they were called to the ward urgently as Mr U had fallen when trying to mobilise to the toilet, even though he had a catheter in place. The doctor assessed Mr U and noted he had a cut on his forehead. On the ‘post fall safety huddle’ document, a nurse noted Mr U’s fall was unwitnessed and there was ‘no bay buddy in place’. The suspected root cause was ‘delirium (confusion) regarding catheter’ and the plan to prevent the next fall was ‘bay buddy at all times’
87. We can see nursing staff did complete a falls assessment for Mr U when he was admitted to hospital in line with NICE guidelines, and they put measures in place to reduce the risk of falls, including the use of bed rails and increased supervision in the form of a bay buddy. There was a lapse in the ‘bay watch’ in the bay Mr U was nursed in on 19 January, which the Trust has acknowledged. Mr U was therefore not appropriately observed by staff when he fell on 19 January.
88. We recognise there were staffing issues during this period, and this may have impacted the level of care provided. Had a member of staff been on ‘bay watch’ as they should have been, we consider there was a likely possibility they would have seen Mr U trying to get out of bed. Whilst we cannot definitively say Mr U would not have fallen if he had been supervised, we think there was a missed opportunity to prevent his fall.
89. Mrs U questions whether the shock of the fall and/ or the broken ribs sustained in the fall could have perforated her husband’s bowel causing the peritonitis and sepsis and contributing to his death. Our physician adviser tells us a fall of this nature would have virtually no chance of perforating the bowel. Mr U sustained broken ribs in the fall, which can cause injuries to the lungs. The fall may have caused an injury to his chest wall, impacting his breathing. Even in a frail patient, a fall from standing height would be exceptionally unlikely to have been associated with sufficient force to cause a fractured rib to perforate an organ. If the fall had caused a perforation of an organ, this would almost certainly have been apparent very soon afterwards, but there is no indication of this in the notes.
90. We recognise the fall was incredibly distressing for Mrs U and we are very sorry to hear about this. We will further consider the impact of this below.
Nutrition
91. Mrs U says the Trust did not provide her husband with adequate nutrition throughout his admission and this contributed to his declining clinical condition, leading up to his death.
92. The Trust say it was documented Mr U had a poor appetite dating back to 2018. It says the dietician team reviewed Mr U regularly due to his poor oral intake. He had been referred to them from the renal dieticians at Brighton. It says dieticians had prescribed Mr U nutritional supplements as part of the Malnutrition universal screening tool (MUST) regime.
93. NICE Guidance on nutrition support for adults say patients should have had a nutritional risk assessment completed using a validated tool such as malnutrition universal screening tool (MUST), within 24 hours of admission to hospital. This Trust nutrition policy is reflective of the NICE guidance and says the patient should have a MUST score completed within 24 hours of admission.
94. The MUST screening tool calculates a patient’s overall risk of malnutrition based on their body mass index (BMI), weight loss and acute illness. A score of zero means no risk, a score of one equals medium risk and a score of two or more means high risk.
95. The notes show the Trust completed a MUST assessment for Mr U on 28 December and his score was two, which put him in the high-risk category. Clinicians started a hydration/nutrition care plan for Mr U. The actions required from this care plan were:
• encourage food/fluid • maintain fluid balance chart • MUST assessment weekly • use of food chart • assist patient with feeding if needed
96. We can see he was identified as being high risk of malnutrition even based on his estimated weight, and a care plan was put in place.
97. Nursing staff completed regular flood and fluid intake charts during his admission. On 3 January, the nursing staff noted they assisted Mr U with his meal because he was sleepy. On the food charts on subsequent days, it says Mr U ‘ate a small amount of food’ or had a food supplement shake.
98. A dietician also carried out a number of reviews on 6, 7, 11, 12 and 13 January. On 6 January, the dietician noted Mr U was underweight based on his estimated weight. The plan was to weigh Mr U, encourage oral intake and continue the assessment the following day. On 7 January, the dietician prescribed food supplements. The dietician noted on 12 January, Mr U was not able to meet minimal nutritional requirements, and he was too tired to be weighed. They noted a short-term nasogastric feeding tube (NGT) may be considered to support nutrition. An NGT is a tube passed through the nose, down through the throat, and into the stomach and is used for delivering food and/or medication to the stomach. On 13 January, Mr U reported there was an improvement in his appetite, and he was having 2-3 food supplement shakes a day. The dietician noted there was no requirement for NGT is he was managing his supplement shakes.
99. We are very sorry to hear Mrs U’s concerns about her husband’s nutrition. It is clear from the records Mr U had a poor appetite during his admission. We consider nursing staff carried out a nutritional assessment in line with the NICE guidance and put an appropriate plan in place. Our nursing adviser says it appears staff did try to encourage and manage Mr U’s nutritional needs, and we can see evidence of this in the notes. Dieticians carried out regular reviews and prescribed food supplements when Mr U was not managing to eat. We consider the Trust acted in line with relevant guidelines and we cannot see there was a failing.
Communication/ carers passport:
100. Mrs U says the Trust communicated poorly with her during her husband’s admission. She says it was very hard to speak to anyone who had control of her husband’s care. She says she asked the Trust to issue her with a carer’s passport on the day of her husband’s admission as she was his main carer, but the Trust did not provide this until 17 January. The Trust acknowledges there was a delay in providing Mrs U with a carer passport and says it recognised communication could be improved.
101. GMC good medical practice guidance says, ‘you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support (paragraph 33)’.
102. The Carer Passport website explains ‘a carer passport in a hospital is a simple tool which identifies someone as being in a caring role for one of the hospital’s patients, involving them more fully in the patient’s care, and connecting them with further support’. The Trust’s website explains a carers passport is a small card that carers can carry with them to show they are caring for a loved one in hospital and get the help they need to do so. It says the Carer’s Passport will be issued by ward staff to the carer and is recognised by staff throughout the Trust. The Trust say it is happy to support carers in any way that they can, such as arranging open visiting, enabling them to eat meals with their loved one or to stay with them overnight in a reclining chair by their bedside. There is no specific guidance setting out specific eligibility criteria or when the carers passport should be issued.
103. The notes show a specialist registrar doctor called Mrs U on 7 January and explained Mr U was very unwell and the plan for peritoneal dialysis. On 11 January, a doctor noted they updated Mrs U on the ward. There was a family meeting on 17 January which Mrs U attended along with Mr U’s daughter and clinical staff discussed his condition. On 19 January, there is a further note of a discussion with Mrs U.
104. Our physician adviser tells us there was an appropriate number of contacts with Mrs U documented in the notes during her husband’s admission. We appreciate Mrs U felt that ‘no one team seemed to know what is going on’ and it was difficult to speak to the leading doctors. This appears to be reflective of the lack of consistent consultant input and the involvement of various teams during the admission as discussed in the sections above.
105. Whilst there is no set guidance about when a carers passport should be issued, we can see from the notes there was a lengthy delay and Mrs U only received towards the end of the admission. The Trust has also acknowledged it should have arranged a carers passport sooner.
106. Our physician adviser explains had the Trust issued the Carers Passport earlier in the admission, this would have allowed Mrs U more open visiting to be with husband and to possibly assist with activities of daily living. It would also have enabled her to be more informed of her husband’s progress. We understand the lack of coordinated communication from the consultants in charge of her husband’s care and the delay in issuing the carers passport would have been very frustrating for Mrs U at an already incredibly difficult time.
107. The Trust has acknowledged there was a delay in providing the carers passport and communication could have felt disjointed because the number of teams involved with her care. The Trust included recommendations in its investigation report for improvements including:
• education of staff in relation to prompt provision of Carers Passport • improved communication with families, including better explanations of care and reason for this
108. The NHS Complaint standards say organisations should take action to make sure any learning is identified and used to improve services. We can see the Trust has acknowledged what has gone wrong and taken action to make improvements in line with NHS standards. We consider this is enough to remedy what went wrong and we will not take any further action on this.
Complaint Handling:
109. Mrs U complains about how the Trust investigated what happened and how it responded to her complaint. She says there were considerable delays in the Trust providing her with a response and she had to chase regularly. Mrs U also says there was a lack of candour in the process and the investigation report contained contradictions, failed to address important details and does not correspond with ward notes. She says the Trust has not acknowledged responsibility or accepted accountability.
Delays:
110. The local authority social services and NHS complaints regulations say:
14. (2) As soon as reasonably practicable after completing the investigation, the responsible body must send the complainant in writing a response, signed by the responsible person, which includes— (a)a report which includes the following matters— (i)an explanation of how the complaint has been considered; and (ii)the conclusions reached in relation to the complaint, including any matters for which the complaint specifies, or the responsible body considers, that remedial action is needed; and (b)confirmation as to whether the responsible body is satisfied that any action needed in consequence of the complaint has been taken or is proposed to be taken; (3) In paragraph 4, “relevant period” means the period of 6 months commencing on the day on which the complaint was received, or such longer period as may be agreed before the expiry of that period by the complainant and the responsible body.
(4) If the responsible body does not send the complainant a response in accordance with paragraph 2 within the relevant period, the responsible body must: (a) notify the complainant in writing accordingly and explain the reason why; and ( (b) send the complainant in writing a response in accordance with paragraph 2 as soon as reasonably practicable after the relevant period.
111. The NHS Complaint standards say organisations should give fair and accountable responses that:
• set out what happened and whether mistakes were made • fairly reflect the experiences of everyone involved • clearly set out how the organisation is accountable • give colleagues the confidence and freedom to offer fair remedies to put things right • take action to make sure any learning is identified and used to improve services
112. We can see from the complaints file, the Trust contacted Mrs U on 21 January 2022 and said there would be an investigation following her husband’s death. On 7 July 2022, the Trust called Mrs U to say the investigation was in progress and apologised for the lack of communication.
113. On 23 July 2022, Mrs U emailed the Trust with the complaint points she wanted the Trust to address during its investigation. During September 2022, there are several emails and calls between Mrs U and the Trust about arrangements for sharing the investigation report. Mrs U attended a meeting on 22 September 2022 to go through the draft report.
114. There were emails back and forth about delays with the report. The Trust shared the serious incident report with Mrs U on 25 July 2023.
115. On 12 September 2023, Mrs U attended a meeting with the Trust to discuss her complaint. On 9 May 2024, the Trust wrote to Mrs U confirming it had nothing further to add and signposted her to PHSO.
116. We can see there were lengthy delays with the Trust’s complaints process. There were several periods where the Trust failed to keep Mrs U updated throughout the investigation process. We recognise this would have been very frustrating and upsetting for Mrs U when she was waiting for answers. This is not in line with NHS complaints regulations or standards, and we consider this was a failing.
Contradictions/ failed to address important details:
117. We consider the Trust’s responses met the standard set out in the NHS regulations as they contained explanations of what happened and considered each of Mrs U’s questions in turn. It also identified where some actions could be taken to improve services. We therefore cannot see it got something wrong. We appreciate Mrs U was not satisfied with the answers the Trust provided, and this is why she has escalated her complaint to us to carry out an independent investigation.
Impact:
118. Mr U very sadly died on 20 January 2022. There was no postmortem, and his cause of death was recorded on the death certificate as follows:
1 (a) septic shock (b) acute peritonitis 2. Fall, right humeral and wrist fractures, left rib fractures, end stage renal failure and diverticular disease
119. Septic shock is a serious condition that occurs when sepsis, the body’s extreme response to an infection, leads to dangerously low blood pressure. Peritonitis is an infection of the peritoneum (the lining of the abdominal cavity). Peritonitis is a serious complication of ischemic bowel or bowel perforation (hole in the bowel).
120. We cannot definitively say Mr U’s management, or the clinical decision making would have been different had a consultant reviewed him regularly or he had transferred to a medical ward. We have seen senior input on a medical ward with appropriate assessments could have potentially allowed for optimisation of Mr U’s fluid status and consideration of anticoagulation. Anticoagulation could have improved Mr U’s condition, but it could have also worsened it, given the risk of significant bleeding. Our physician adviser says better fluid management would most likely have resulted in Mr U becoming less dehydrated, which would have reduced the degree of his kidney impairment, confusion and discomfort. On balance, our physician adviser says it would not have impacted Mr U’s eventual outcome to more than a small degree. It was unrelated to the primary causes of Mr U’s death (sepsis and acute peritonitis).
121. We have seen Mr U was given too many opioids resulting in opioid toxicity. Our physician adviser explains opioids can make the bowels more ‘sluggish’, but they would not directly cause perforation, peritonitis or an ischaemic bowel. The main impact of the opioids would have been on Mr U’s respiratory (breathing) system, making chest infections more likely. He would also have become generally weaker.
122. As noted above, the fall is very unlikely to have caused a perforation of Mr U’s organs, but it did cause a chest wall injury (lower rib fractures). Our physician adviser tells us an injury to the chest wall can be very serious in elderly, unwell patients such as Mr U. The pain associated with this means they cannot expand their lungs as well as they should do, also leading to an increased risk of chest infections. Mr U developed sepsis following the fall and this was in part due to pneumonia (inflammation of the lungs, usually caused by infection).
123. The fall and rib fractures were listed as contributory factors to Mr U’s death (in part two rather than part one of the death certificate). We recognise the opioid toxicity and fall increased Mr U’s risk of developing a chest infection, and he later developed pneumonia. Our physician adviser tells us although this could have caused Mr U’s death in time, his abdominal problem was the more immediate cause of his death, which was unrelated.
124. Overall, we cannot say that Mr U’s death could have been avoided had the failings not happened. Mr U had a lot of medical problems and there was a delicate balance of the risks as by treating one condition, it could potentially cause other adverse effects. If Mr U had been transferred to a medical ward and the management of his atrial flutter, fluid balance and opiate analgesia had been better managed, our physician adviser explains his chances of survival would still not have been more than 50%. Even if those factors had been managed better or the fall had been avoided, there was still sadly a significant risk that Mr U would have died. We consider there were potential missed opportunities for Mr U to have had better management, but we cannot say it is likely this would have resulted in a better clinical outcome. Mrs U will be left never knowing if these could have made a difference which is a significant injustice. We have also seen these failings likely contributed to increased pain and discomfort for Mr U during the last few weeks of his life.
125. We recognise these failings have caused Mrs U a great deal of distress and upset and left her with outstanding questions. We are very sorry to hear about this and we hope our findings provide her with some reassurance.