Fitting a catheter
13. Mr A told us what a determined person Mrs A was and how she knew her own mind and what she wanted. He told us that she did not want a catheter fitted and would not have agreed to this willingly.
14. We understand how well Mr A looked after his wife at home, and how upsetting it was for him to find out the Trust had fitted a catheter.
15. We asked our adviser about the reasons for fitting the catheter. They explained Mrs A was very unwell, and it is part of the standard management for someone who has signs of severe infection to consider using a catheter.
16. The detailed records show Mrs A’s bladder was visible on a bladder scan (this can mean a patient is retaining urine). As she had not passed urine for several hours the Trust needed to insert a catheter. This is in line with the sepsis guidelines which say ‘measure urinary output: this may require a urinary catheter’.
17. For these reasons we do not see any indications of failings in the Trust’s decision to fit a catheter.
18. We can see it was written in the records that Mrs A had said ‘do whatever you think is necessary’. Mr A told us these are words his wife would never use. As we weren’t there to witness the discussion we can’t know for certain what was said. We accept that Mr A knew his wife better than anyone, and so knew what she would have probably said.
19. We should explain that medical records are usually written a little while after the care and treatment has been given. This is because nurses have to wait for a break in their caring duties to do this. Because of this, what is written down is not always exactly what was said, records note the general sense of what was discussed.
20. The records show a detailed discussion with Mrs A. While we can’t know the exact words she used, we can see the nurse very clearly asked about inserting a catheter and Mrs A did consent to this.
21. This was in line with the guidance outlined on the NHS website ‘Overview, Consent to treatment’. This says someone can give verbal consent when a treatment is explained to them. For this reason we have not found any indications of failings.
End of life plan
22. We understand how difficult it must have been when the doctors told Mr A that Mrs A was at the end of her life. Mr A told us he had discussed this with Mrs A beforehand, and so he knew what she wanted. He said he had a very clear recollection of what he told the doctor, and what they agreed for the end of life plan.
23. Mr A said he had asked the doctor to begin the plan to make Mrs A comfortable straight away. He said when the family gathered this hadn’t happened, which was upsetting for everyone. We were truly sorry to hear about how much the memory of this still affects Mr A and his family.
24. The initial communication about end of life planning was in line with the NICE guidance, which emphasises the need to provide practical and emotional support to carers. The family were told Mrs A was at the end of her life and were allowed time to process and understand this.
25. Our adviser explained that end of life care means a move from active treatment to symptom control, to address any distress, pain and agitation in the individual. There is no increased sedation provided, but interventions that are not deemed beneficial are stopped.
26. Mr A told us the Trust changed the plan deliberately. It is clear there is a difference between what Mr A understood would happen and what did happen. This was acknowledged in the written records at the time.
27. It appears there was a time delay between the decision to move to end of life care, and the beginning of measures to support this. The records show the Trust considered whether all the family were able to be there, before the process began.
28. We recognise how upsetting this was for the family, and we can see the Trust did the right thing by apologising for this communication breakdown at the time. We can see the Trust also apologised in the complaint meeting for not getting things right.
29. The Trust meeting minutes described actions it was taking to try and improve the understanding of what people want at the end of their lives. We think the apologies and these actions go far enough to mean there is nothing extra we need to ask the Trust to do.
Locating Mrs A’s body after her death
30. When Mr A made his complaint to the Trust he wrote ‘Why was l told that my wife's body had been moved to [another hospital] when, in fact, she was still at the [original hospital]?’. He told us that the Trust had lost her body for a few days. We understand how upsetting this must have been at a time when Mr A was already grieving.
31. We can see why Mr A remains upset because the Trust has not made a clear response to this part of his complaint. In the complaint meeting the Trust said the mortuary team had sent a letter to Mr A, stating that the team accepted full responsibility for the confusion.
32. The Trust told us it has no records of the mortuary team writing to Mr A. It explained there was a datix report (for keeping a record of things that have gone wrong) about what happened. This may be what caused the confusion in the meeting.
33. The other information the Trust shared about this in the meeting was correct. The mortuary team accepted full responsibility for the confusion, the Trust apologised, and made changes to the process to stop this happening again.
34. The datix shows the mistake was caused because the staff had not followed the procedure properly. The Trust has made changes in the wording of the instructions to staff, discussed the mistake with the team, and looked at ways to improve arranging viewings.
35. We think the apology and the changes the Trust has made are sufficient to recognise what went wrong, to remedy the distress caused to Mr A and to prevent this happening again.
36. We understand how important this complaint is to Mr A and we thank him for sharing his concerns with us. We hope he will be reassured that we have not found anything to make us think we need to ask the Trust to take further action in relation to the issues we considered.