17. To decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. If we see indications something has gone wrong then we consider the impact this had and what the organisation has done to put things right.
ED care on 26 September 18. Mrs A complains staff at the Trust sent her mother home on 26 September. She feels doctors should have admitted Mrs B to hospital because she was so unwell and vomiting continuously. She is concerned her mother might not have died the Trust admitted her mother earlier.
19. The Trust said there is no record in the notes of Mrs B vomiting. It said staff treated her fractured arm then sent her home. It explained Mrs B was keen to go home, and the acute hospital setting is often unsuitable for elderly patients like Mrs B. It said this is because they are at risk of infection and of their condition getting worse.
20. However, it also said staff did not notice the severity of Mrs B’s symptoms at the time. It agreed with Mrs A that staff should have paid more attention to her mother and treated her as a vulnerable patient. It said they did not appreciate how poor Mrs B’s health was, and said they should have admitted her to hospital.
21. Good medical practice says doctors should adequately assess a patient and identify their problems.
22. Our adviser explained Mrs B’s clinical observations on arrival at ED were all within the normal ranges. The doctor identified her potentially fractured arm, X-rayed the area and got specialist input from orthopaedics. The ED doctor then discharged Mrs B with a referral to the fracture clinic.
23. Our adviser explained based on Mrs B’s medical records from her first ED visit this appears to be appropriate. However, there is important information not included in the records from this attendance.
24. Specifically, Mrs A says her mother vomited several times whilst waiting to be seen. There is no record of this in the medical notes, but we do not doubt that it did happen.
25. Additionally, Mrs B’s notes from her ED attendance the following day show she was jaundiced. Jaundice is a condition where there is too much bilirubin in the blood. Bilirubin is a yellow substance produced when red blood cells breakdown, usually due to liver disease. Her bilirubin level was 120 µmol/L. A normal level is between 0 and 21 µmol/L.
26. Our adviser explained it was very unlikely Mrs B developed jaundice within the 24-hours between her first and second ED visits. They said the problem was likely to have been present when she first attended ED, but there is no record of it.
27. We consider staff at the Trust should have identified Mrs B’s vomiting and her jaundice, and recognised the overall severity of her condition. They did not do so. This was not in line with the guidance in Good medical practice.
28. Therefore, we consider the Trust got things wrong when it decided not to admit Mrs B to hospital at this point. We have therefore looked at the impacts this had.
29. Our adviser explained it likely staff would have admitted Mrs B to hospital on her first ED visit.
30. However, Mrs B had severe problems when she visited ED, including liver disease and kidney disease. This is when the organs no longer work properly. The severity of these two chronic conditions indicates they predated the fracture.
31. It was unlikely her fractured arm caused the deterioration in her overall health. It is very likely that Mrs B was already unwell due to her chronic problems, and these may have contributed to the fall that caused her injury.
32. Mrs B’s health continued to deteriorate despite her hospital admission. It is therefore very unlikely that admission one day earlier would have affected the overall treatment she received or prevented her sad death.
33. This means we cannot link Mrs B’s discharge to the serious impact Mrs A has claimed. Nonetheless, we recognise going home and then returning to hospital was distressing and inconvenient for Mrs B and her family.
34. We understand the distress Mrs A she felt at the time and how worrying these events were for her. She has also experienced a long period of concern that things should have happened differently. We acknowledge how draining this has been and hope our decision can provide some reassurance to her.
35. With this in mind, we have considered what the Trust has done to put this distress right. To do this we have compared its complaint response to our Principles. These set out organisations should identify where they got things wrong and learn from this. They should also apologise for the impact on the individuals directly affected.
36. Our adviser explained Mrs B’s underlying problems went unnoticed against a backdrop of a busy ED. There were likely pressures on staff time at the time which meant Mrs B did not have a named nurse in a private room and the assessment did not include more detail.
37. The Trust’s medical examiner looked at the events and made some recommendations to stop the same thing happening again.
38. The complaint response explained it has started its Stronger Together campaign since the events. The aim is to improve the capacity of its wards and availability of nursing staff. Part of the campaign has resulted in using a dedicated team of porters to transfer patients to a discharge lounge. This means nurses no longer do this task, and more beds are available for patients who need them.
39. Further, the Trust shared Mrs A’s complaint with the staff involved so they could learn from it. The lessons include the missing notes regarding Mrs B’s vomiting and the fact staff should have identified the severity of her condition sooner.
40. We are therefore satisfied these changes address systemic and individual reasons for what went wrong.
41. The Trust also said sorry to Mrs A for what happened. It apologised for the difficult and distressing time she experienced, and how the events made the upsetting death of her mother even worse. Therefore, the Trust has also acknowledged the individual impacts on Mrs A and apologised for these appropriately.
42. Given there is nothing left for us to put right we have decided not to investigate further.
43. We recognise how distressing this experience was for Mrs A and the significant concerns she has brought to us. We understand the worry she experienced that day still lives with her, and why this is such an important issue.
Oxycodone 44. Mrs A says doctors should not have given her mother oxycodone because of her medical history. She says the BNF and NHS website set out that oxycodone is unsuitable for people with a history of alcohol misuse, asthma or liver problems. She says all three of these applied to her mother.
45. The Trust explained it was not appropriate to give Mrs B other commonly used pain killers. It said oxycodone was the right option given the circumstances of her hospital visit.
46. BNF guidelines for oxycodone set out several cautions for the medicine. The cautions for oxycodone advise specific care is used when giving it to patients with: • a history of alcohol misuse or addiction • asthma • liver problems.
47. Mrs B had one dose of oxycodone on 27 September which the medical team then stopped.
48. Our adviser explained these cautions in BNF only apply in certain circumstances. For example, a history of alcohol misuse is a problem due to the risk of addiction to oxycodone. However, a single dose within a hospital setting is unlikely to cause any addiction problems.
49. Furthermore, it is advisable to withhold oxycodone if a patient is having a severe asthma attack. This is because of oxycodone can potentially suppress someone’s breathing. It is safe to give to patients with a history of asthma if they are not symptomatic at the time.
50. In patients with liver disease there is a risk that the body will not use up oxycodone as quickly as normal, and so it may remain in their system longer. A single one-off dose like the one given to Mrs B is unlikely to have resulted in any clinical impact to her.
51. Our adviser agreed with the Trust’s explanation that other pain killers would have been potentially unsuitable too. The most common painkillers in this instance would be paracetamol and ibuprofen.
52. Paracetamol can potentially cause liver damage and ibuprofen is not recommended for people with kidney and bowel problems. Given Mrs B’s underlying liver disease and kidney disease, these medication options would not have been an ideal choice either.
53. We understand Mrs A’s concerns about staff giving her mother oxycodone, and the worry this has caused her. Having taken all the information into account, we consider it was in line with guidance for the Trust to give Mrs B oxycodone on 27 September.
Omeprazole 54. Mrs A complains staff at the Trust did not give her mother omeprazole as planned. She says a nurse advised her the omeprazole would be given on 15 October, and it would be given again on 23 October as well. She doubts it was given continuously for 72hours as nurses said.
55. Omeprazole is a medicine that reduces the amount of acid someone’s stomach makes. It can be used to treat stomach ulcers, like the one Mrs B had.
56. Good medical practice says doctors should provide necessary treatment promptly.
57. Mrs B’s records show doctors prescribed her an oral dose of omeprazole on 15 October and they gave it to her at the time. Doctors prescribed it again on 19 October. The prescription record shows it was given for a three-day period, with the last dose given in the morning of 21 October. There is no indication it was given on 23 October or in the days afterwards.
58. Our clinical adviser explained Mrs B appears to have been very unwell with severe liver disease and significant impairment of her kidney function. The omeprazole was intended to reduce stomach acid and lower the risk of ulcers bleeding. Although Mrs B had some doses of omeprazole, she continued to deteriorate with a progressive illness.
59. Therefore, it appears the omeprazole was appropriate given Mrs B’s condition and given accordingly. When it was decided it would be of no further benefit the omeprazole treatment was stopped.
60. We recognise Mrs A expected doctors to give her mother omeprazole on 23 October. They gave it earlier than this – on 19 October. When doctors gave Mrs B the omeprazole they did so for the 72-hours as advised.
61. Based on our consideration of the evidence we are satisfied the omeprazole was given as prescribed.
End of life communication 62. Mrs A says doctors did not properly inform her and her family about Mrs B’s end of life care.
63. Good medical practice says doctors should be responsive when giving information to those close to the patient.
64. Records show doctors placed Mrs B on the SWAN pathway on 25 October. This is a standard of care used in the last days of someone’s life. Doctors recorded having a discussion with Mrs B about this at the time. She agreed to stop treating her illness, and focusing on keeping her comfortable.
65. Doctors had the same conversation with Mrs A and her sister on the same day. They were both in agreement that end-of-life care was the right thing to do. Another note on 30 October recorded that doctors spoke to Mrs B’s family again about where was best to care for her, and discussed whether it would be in her best interests to receive the end of life care at home.
66. We recognise how stressful this experience was for Mrs A and her family. We understand she felt uninformed about what happened and how that made an already upsetting event even worse.
67. We consider doctors took reasonable steps to keep the family informed as Mrs B’s condition got worse. This was also in line with Good medical practice and giving family important information.
68. Having looked at Mrs A’s complaint we recognise the upsetting experience she has gone through. We understand how these issues have impacted her and the distress she has felt.