Choking incident
25. Dr A is concerned her mother suffered from a chocking incident on 18 November whilst a nurse was assisting her with feeding. We first considered what the Trust did in order to try and prevent such an incident from happening.
26. Our nurse adviser referred us to the CQC guidance, Issue six, Caring for people at risk of choking. It says chocking is avoidable if there is a known risk, following an assessment. Dysphagia is the medical term for swallowing difficulties. If a person with dysphagia is at risk of choking, they will usually see a speech and language therapist (SALT). SALT will put plans into place to tell staff how to prepare their food and drink and reduce the risk of choking.
27. Our nurse adviser also referred us to CQC guidance, Meeting nutritional and hydration needs referring to Regulation 14 the Health and Social Care Act 2008. It says staff should include people's nutrition and hydration needs when they make an initial assessment of a patient’s care, treatment and support needs. The assessment and review should include risks related to people's nutritional and hydration needs and may lead to a SALT review.
28. The Trust carried out a neurological assessment and stroke review on 17 November. The doctor considered the face and mouth muscles and noted no concerns with Mrs A’s swallow. Therefore, there was no need for the doctor to request a review by SALT because there was no risk of choking, in line with both the CQC guidance quoted above. We have also noted that medical staff gave her various forms of oral medication without there being a problem noted, suggesting her ability to swallow was not a concern.
29. We understand it must have been deeply upsetting for Dr A to find out her mother had choked during her lunch. It is our view the Trust carried out an appropriate assessment and did not need to request a review from SALT in line with both the CQC guidance quoted above. It appears there were no concerns around Mrs A’s swallowing ability prior to the choking incident.
30. However, we know Mrs A did then go on to have a choking incident. We do not underestimate how distressing this was for her and her family.
31. We therefore considered what happened at the time. We know a nurse was helping Mrs A with her feeding when she experienced the choking incident. Our nurse adviser helped us understand that if a patient does not have any suspected swallowing difficulties but requires assistance with feeding, there is no guidance on preventing choking. They referred us to the John Hopkins Medicine website, which provides general information on choking first aid and prevention. It suggests cutting food into small pieces, chewing food slowly and thoroughly, especially if someone is wearing dentures. It also encourages people not to laugh or talk while chewing and swallowing.
32. The medical records only tell us that a nurse was assisting Mrs A with her lunch, and she choked on her food. We understand people can choke on their food at any point. But, we do not know exactly what was happening at the time. The record does not tell us any specific detail about the feeding itself. We have not been able to say that the nurse could have prevented the choking episode at the time they assisted with feeding because we do not have enough information.
33. The Trust explained it would not expect a nurse to routinely document the level of detail about how staff were feeding a patient at the time. We consider this is reasonable because this level of detail is what would be included in an incident report, not the medical records. It is our view the Trust should have obtained more detailed information after Mrs A choked on her food and have considered this in more detail below.
Incident reporting
34. Dr A complains the nurse involved and other staff members on the ward did not complete an incident report at the time. This meant the Trust did not carry out an immediate investigation to identify why her mother had suffered a choking incident and if it could have prevented it.
35. The Trust’s Incident Reporting and Investigation Policy explains an incident is an unexpected and unplanned event, and it should report all incidents regardless of the level of impact. It explains it should report all incidents, or near misses, under the Trust’s incident reporting system at the earliest opportunity after the incident occurs. They should include a record of what happened and what action it took.
36. It will then investigate the incident depending on the level of impact this had on the patient and the level of organisational learning, or the risk identified. A manager will review the incident report and decide what action to take.
37. We understand it must be concerning for Dr A that the Trust did not report the choking incident. Mrs A’s choking event was unplanned and unexpected. It is our view the Trust should have reported it under its policy and to the person in charge of ED. We cannot say this would have led to an immediate investigation because this would depend on what information the person reporting it gave.
38. We know a manager would have reviewed the incident report, in line with the Trust’s policy, and this would have led to the manager asking further questions and deciding whether to investigate. An incident report completed after the event would have provided more information and detail about what happened. We have considered this further in the impact section of this report.
Death certificate
39. We next considered Dr A’s concern the consultant did not initially fill in Mrs A’s death certificate correctly. She explains the consultant’s initial entry for the cause of death was ‘pneumonia’. When she raised concerns about this, the ME amended this to ‘aspiration pneumonia’ and ‘frailty of old age’. She explains this still does not accurately represent the sequence of events that led to her mother’s death.
40. Dr A considers the death certificate should clarify her mother had a choking incident whilst at the Trust, leading to ‘aspiration pneumonia’. She feels this should have prompted an urgent review of her care and possible involvement from the coroner.
41. We understand it must have been very distressing to see the Trust had not noted her mother’s cause of death correctly. The Trust explained the doctor initially did not include the term ‘aspiration pneumonia’ in Mrs A’s death certificate, which was an oversight. It apologised for this and provided an amended death certificate. The Trust did not comment on whether the ME should have also noted Mrs A suffered from a choking incident.
42. To establish what should have happened, or ME adviser told us that choking is not a term an ME would recommend the attending doctor uses on a death certificate. We considered Notification of Death Regulations and RCPath, which provides information about MEs and has a guidance list for causes of death. This list does not include choking but does include aspiration pneumonia. It says doctors must record an acceptable cause of death in part one of the death certificate. It is our view that there was no requirement for the ME to include choking as a cause of death on Mrs A’s death certificate because RCPath does not include it in its cause of death list.
43. For the cause of death as aspiration pneumonia, it says to ‘refer to the coroner unless supported by an acceptable cause of death’. It explains the term frailty of old age is ‘acceptable provided the deceased is 80 or over’. Because Mrs A’s death certificate referred to both, there was no requirement to refer her case to the coroner.
44. Our ME adviser explained the purpose of an ME is to achieve an accurate cause of death, to detect problems in treatment and care (especially where these may have caused or contributed to death) and liaise with the coroner.
45. A nurse was helping Mrs A with her eating at the time she choked. In this case there is little information about the circumstances of the key moment when she choked on the food.
46. Our ME adviser told us that if Mrs A choked because there was a breach in the nurse’s duty of care to provide safe assisted feeding, then the ME should have considered this a reason to notify the coroner.
47. Our ME adviser helped us understand this level of detail or certainty might only come from an investigation to establish if there was a breach of duty to provide safe assisted feeding. The ME scrutiny is there to detect the possibility of a breach of duty but has no role to investigate this.
48. We also considered the documents completed by the ME at the Trust. The ME recorded their view taken from the medical notes and the cause of death in the ‘medical certificate of cause of death form’. When they completed the ME’s advice and scrutiny form, they did not provide their narrative about the process they undertook and how they reached their conclusion. They left the relevant boxes on the form blank.
49. We understand this has been an area of real concern for Dr A. Because there was no incident report, there was no detail available about what happened. Whilst we have seen no evidence the Trust needed to refer the matter to the coroner based on the evidence it had, the information in the forms completed by the ME lacked information and this amounts to a failing. We have considered the impact of this further below.
SJR
50. We then turned to Dr A’s concerns about the Trust’s SJR. RCPhy, Using the standard judgement review method says in an SJR trained clinicians use statements to comment on the quality of healthcare in a way that allows them to reach a judgement. It relies upon the reviewer looking at the medical record in a critical manner and commenting on specific phases of clinical care.
51. The Trust’s Mortality Review Policy explains it will review all inpatient deaths to ensure it learns lessons to improve clinical care. The mortality review process will include a programme of SJR. An SJR comprises of two specific aspects, firstly a judgement comment and score made about each care phase and then the overall care provided.
52. The SJR guidance notes say the Trust must avoid recording facts and provide explicit judgements and not to automatically score a five (excellent) and there should be a clear and explicit justification for its scoring. The guidance refers to the reviewer interviewing the member of staff involved to provide further explanation.
53. We first looked at whether the SJR included all the key information. The SJR shows Mrs A had a chocking incident during lunch with aspiration. It explains the nursing documentation around the incident was poor and medical staff did not complete an incident form. It confirms its staff carried out a medical review and physiotherapy assessment after the incident. It did not comment on Mrs A’s specific drop in oxygen saturations and what the physiotherapy and medical team did when they attended. There was no reference to the X-ray and its findings. Our ME adviser helped us understand the reviewer should have considered this in detail as part of the SJR. The reviewer should have provided its own judgement about this, in line with RCPhy and its own guidance notes.
54. Dr A is also concerned the Trust did not gather statements from the nurse involved, or staff that witnessed the incident. The Trust did note that the nurse had left the Trust, however we have seen no evidence it considered speaking to any of the other medical staff involved in Mrs A’s care at the time of the incident.
55. Our ME adviser told us SJRs are a learning tool, and it should not be mistaken for an investigation. In line with its SJR guidance, it could have contacted the nurse to gather further information. We have already identified that if the Trust had completed an incident report, this would have led to further evidence becoming available about the incident which it could have used during the SJR.
56. Dr A sent her concerns to the Trust about its original SJR report scoring. She complains her mother’s records do not support its decision her mother’s care was ‘very good’ due to the lack of information. As a result, the Trust removed the SJR scoring for the ‘admission phase’ of care involving the choking incident due to the lack of information it had. The overall care remained as ‘very good’.
57. Our ME adviser explained an SJR should contain a narrative and a summary judgement of each phase of care, and they may attract different ratings. For example, one significant event in a long admission can turn the overall judgement into poor care despite presence of evidence of other good care.
58. The Trust removed the SJR scoring in the ‘admission phase’ because it said it did not have enough information to determine the events. The Trust did not amend the overall care scoring in the SJR which it scored as a four, very good. It concluded ‘it is regrettable that the choking incident occurred during the attendance in ED and not completely clear how it happened but was responded to well’. The SJR included a review of two other phases, ‘ongoing care phase’ and ‘end of life’ phase, it scored both a five as excellent.
59. It is our view that if the Trust could not provide a rating for the ‘admission phase’, then it is not reasonable that it gave an overall rating of very good. This does not provide a true reflection of the events, in line with RCPhy and its own guidance notes.
60. We understand it must be deeply concerning for Dr A that the Trust did not change the overall score in its SJR. The Trust missed detailed information from the SJR about the choking event and should have contacted the nurse involved to gather further information. It removed the scoring from the ‘admission phase’ but did not amend the overall care score.
61. If the Trust was unable to score the ‘admission phase’, due to lack of information, we cannot see how it was able to say the overall score was a four, very good. In its summary it referred to the choking incident, but did not explain its justification for the overall score, which is not in line with the SJR guidance notes. This is therefore a failing. We have considered the impact of this further below.
Impact
62. Dr A explains she is left not knowing why her mother suffered the choking incident and whether the Trust could have prevented it. She said this has caused her and her whole family significant upset and distress. She also explains if the Trust had reported the incident promptly then a detailed more appropriate investigation into the events that occurred would have happened sooner. She explains the failings in the SJR meant it incorrectly concluded it could not say if the choking incident led to her mother’s death.
63. We understand this has been and still is a significantly upsetting time for Dr A and her family.
64. We have found the Trust did not need to take steps to put any plans in place to prevent aspiration because there was no sign of Mrs A having any swallowing concerns. We have not been able to say that the nurse could have prevented the choking episode at the time they assisted with feeding because we do not have enough information. As a result, we are not able to say if the Trust could have prevented this incredibly distressing event. We understand this will be deeply upsetting to read.
65. The Trust did not complete an incident report at the time, its ME’s advice scrutiny form lacked information and when it carried out its SJR, missed key information and did not amend the overall rating. We can understand this caused Dr A further concern.
66. It appears there was a domino effect of each of these steps. We cannot say that if the Trust had reported the incident straightaway, it would have led to an immediate investigation, in line with the Trust’s policy. If it had carried out an incident report, a manager would have reviewed this and would have decided what action to take and spoken to the nurse and staff involved in the incident. The Trust would have been able to check the medical records at that stage to determine what information it had. This could have led to a better understanding of its SJR, an interview with the nurse and provided more meaningful responses and answers to the ME and Dr A. We appreciate this has left her with uncertainty about what the outcome would have been if the Trust had carried out these steps. We understand this has caused further upset to her and her family.
67. Dr A would like the Trust to implement service improvements, to ensure these failings do not reoccur. When considering the injustice, we have considered what actions the Trust has taken to put this right. When the Trust responded to the complaint it did not take any action because it did not find anything went wrong during its own investigation. Although it did acknowledge that if it had completed an incident form at the time, it may have prompted a different investigation process which would have focused on the choking incident itself.
68. The Trust has since told us it now investigates and reports incidents differently. It has a policy for The Patient Safety Incident Review Framework (PSIRF). PSIRF aims to improve support for staff, patients, and families affected by an incident and has a stronger focus on learning and improvement.