Transfer on 10 February
21. TPN is a medical treatment used when a person cannot eat or absorb food through their stomach or intestines. Instead of using the digestive system, TPN delivers nutrients directly into the bloodstream through a CVC line.
22. The NICE guideline on nutrition support for adults provides advice to healthcare professionals on how to identify and treat adults at risk of malnutrition, including when to offer TPN. The guideline sets out that care and treatment should be ‘patient-centred’ and ‘take into account’ their needs.
23. The Trust’s policy on parenteral nutritional support says its dieticians are available to assess patients for TPN between Monday and Friday. It says any order for TPN must be provided to its pharmacy by 3pm on Friday. Mr B was admitted to the Trust’s SAU on Friday evening, outside of these timeframes.
24. The Trust’s policy also sets out an ‘out-of-hours’ protocol. It says this protocol is in place to place to ensure new patients are not overfed and can be reviewed by the dieticians after 48 hours. As Mr B had not yet been assessed by the dietician, the Trust’s out-of-hours protocol cannot apply here.
25. Mr B was, however, assessed by a dietician at the hospital he was initially admitted to, prior to his transfer to the Trust. The dietician made detailed notes about Mr B’s prescription, including how much in fluid, electrolytes, and vitamins should be included. We can see these notes were made available to the Trust when Mr B was transferred.
26. Our dietician adviser said the Trust could have started Mr B on TPN over the weekend because he had an existing prescription. The Trust’s policy does not set out what should happen if a patient is transferred out-of-hours with an existing TPN prescription.
27. We considered if this meant Mr B should not have been transferred until Monday 14 February. Our surgeon adviser explained the Trust would have needed to assess Mr B’s fitness for surgery and prepare him for surgery. They said it was appropriate for the Trust to admit Mr B as soon as a bed became available on its surgical assessment unit.
28. Therefore, while we are not critical of the Trust for transferring Mr B when it did, we think the gaps in its policy meant it could not provide him with the patient-centred care described in the NICE guideline. The policy did not allow the Trust to take his needs or circumstances into account for the period where it was recognised he needed TPN between the evening of 10 February and the morning of 13 February. We think the Trust missed an opportunity to provide Mr B with the treatment he needed. This is a failing.
29. As we have seen, Mr B was eventually assessed by the Trust’s dietician on Monday 13 February. His treatment with TPN started on the morning of 14 February. We think the failing meant Mr B went without TPN for three days.
30. Miss B told us the delay in providing TPN in turn led to the Trust delaying Mr B’s operation by one week. We can understand why she feels this way. There is evidence the Trust’s initial plan was for Mr B to have surgery during the week commencing 13 February, although we cannot see evidence that it had been scheduled for a specific date.
31. Our surgeon adviser explained the Trust needed to assess Mr B’s fitness for surgery and it was supported by the clinical evidence available for the surgeon to say that Mr B’s nutritional status needed to improve before it could take place. They explained improving a patient’s nutritional status before surgery means providing them with the opportunity to support their immunity and strength to ensure the body is better equipped to handle the stress of an operation.
32. Having considered the evidence available, we understand from our surgeon adviser that it is unlikely that the three-day delay in providing TPN caused the decline in Mr B’s nutritional status. The evidence we have seen indicates Mr B had lost around 10kg over the two months prior to his admission to hospital. When he was assessed by the dietician on 10 February at the local hospital he initially went to, he was noted to be malnourished and at risk of refeeding syndrome. We cannot see a difference between the outcome of Mr B’s assessments on 10 February and 13 February, which indicates there was no decline in his condition between those dates.
33. Our surgeon adviser also explained three days is not a clinically significant length of time for a person to go without food. They said it is generally after seven days that a person would be physically impacted by not eating.
34. We hope our work helps Miss B understand why the Trust’s delay in treating Mr B with TPN was unlikely to have been the reason why his surgery took place a week later.
35. However, we consider there is an injustice here to Miss B. Miss B learned her father had stomach cancer on 9 February, the day before the Trust transferred him. She was already deeply concerned about his visible weight loss and how little food he had been able to eat over the months leading up to his diagnosis.
36. In her complaint letter to the Trust, Miss B said she expected Mr B would start TPN as soon as he arrived at the Trust on 10 February. She says when this did not happen, she felt her father was ignored and uncared for over the three days. She told us he was ‘begging nurses’ to feed him and he was getting weaker by the day. We can see those three days would have been intensely distressing for Miss B, as she knew her father was not receiving the treatment he needed, just at the point where his illness was at its most severe and she felt he was at his most vulnerable, and despite her efforts she had no way of resolving the barrier in place.
37. Miss B knew how seriously unwell Mr B was and how little food he had eaten since he started to experience symptoms of stomach cancer. Even after the point the Trust provided TPN on 13 February, the distress caused to her by the error continued, as it led to Miss B’s fear that the days without TPN would have a decisive clinical impact on Mr B’s condition and potentially contribute to his death. Naturally, her fear was compounded when Mr B died suddenly on 25 February.
38. Her fear that the period of missed TPN contributed to her father’s death has continued until now, as it is only at this point she has received an explanation as to what happened and why on the balance of probabilities that missed period did not contribute to Mr B’s death at that time. We think the Trust had an opportunity to explain its actions when it responded to Miss B’s complaint.
39. Unfortunately, the Trust’s explanation was inadequate because it only explained its policy, rather than considering Mr B’s specific clinical circumstances. This is not in line with our NHS Complaint Standards, which say organisations should ‘give a clear, balanced account of what happened based on established facts’ and meant Miss B has remained concerned about whether the failing contributed to her father’s death for a prolonged time.
Response to deterioration on 24 February
40. GMC Good Medical Practice sets out what doctors should do to provide good clinical care. It says when doctors assess, diagnose, or treat patients, they must examine them, adequately assess their conditions, and take account of their history. They also say doctors should 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.
41. We looked at how the doctors responded to Mr B’s deterioration. Our surgeon adviser said the first sign that Mr B had started to deteriorate was at midnight on 22 February, when he suddenly developed a high temperature. The records show the Trust thought he may have a PICC line infection, so it collected a sample from the tip of the line and sent this to the Trust’s microbiology team. It prescribed and treated Mr B with antibiotics. The Trust also took Mr B’s PICC line out.
42. We understand from our surgeon adviser that the Trust acted in line with GMC Good Medical Practice because the doctor promptly investigated the cause of Mr B’s sudden high temperature, took appropriate steps to diagnose an infection, and prescribed antibiotics.
43. Our surgeon adviser said the records show Mr B appeared to improve once the line was taken out. His temperature returned to normal, and his NEWS remained settled. NEWS, short for National Early Warning Score, is a simple system used by doctors and nurses to spot if a patient’s health is getting worse. It is a calculation of how far outside a normal range a patient’s vital signs are, including temperature, heart rate, and pulse.
44. On 24 February, Mr B had a slightly raised heart rate and a low urine output. A doctor assessed him just before 2am on 25 February. They prescribed intravenous (IV) fluids to treat his possible dehydration, and bisoprolol, a beta blocker, for his slightly elevated heart rate.
45. Again, we understand from our surgeon adviser that the Trust acted in line with GMC Good Medical Practice at this point. They said the records show the doctor thoroughly examined Mr B and promptly treated his low urine output and elevated heart rate.
46. On the morning of 25 February, the surgeon assessed Mr B during a ward round. Our surgeon adviser said the records show Mr B had not deteriorated significantly since he was seen by the doctor overnight, but he was complaining of shortness of breath and tenderness in his abdomen.
47. We can see from the records that the surgeon was concerned Mr B might be suffering from complications following his operation. They took a blood test to look at the gases in Mr B’s blood, including a lactate measurement (lactate in a blood gas test is a key marker that reflects how the body is handling oxygen and energy production, especially under stress or illness). The surgeon arranged for the intensive care team to assess Mr B. They also prescribed him oxygen due to his shortness of breath, arranged a scan, and arranged a review of his pain medication. Very sadly, Mr B suffered a cardiac arrest within 30 minutes of the surgeon making these arrangements.
48. Our surgeon adviser said the records show the surgeon did everything necessary to investigate and diagnose the cause of Mr B’s deterioration. They said although Mr B was clearly unwell, there was no indication that he was about to suffer a cardiac arrest.
49. We understand Miss B’s concern that had the surgeon reviewed Mr B sooner, there would have been more time for the Trust to recognise how unwell he was and prevent his death. On balance, we do not think the evidence supports this would have been the case. We think the surgeon made their decisions based on Mr B’s clinical presentation at the time, and there is no evidence they could have done anything to prevent or predict his sudden and rapid deterioration.
50. We do not find evidence that the Trust could have responded more quickly to Mr B’s deterioration. The evidence available shows that on each occasion where Mr B showed signs of deterioration, the doctors acted as they should have done by examining him, investigating the cause of his deterioration, and promptly providing treatment, in line with applicable guidelines and standards.
51. We do not see a failing here. We know this time was extremely worrying for Miss B. We hope we have provided a degree of reassurance that in our independent view the evidence available shows the doctors acted within guidance when they responded to Mr B’s deterioration.