20. The Trust’s response and SJR mention that there was no indication in the records that Mrs C complained of chest pain. Our review of the records confirmed this. Miss C accepted this was the case; she complained to us essentially about the final few hours when she says her mother was experiencing chest pains on the afternoon of 11 January and nobody came to check on her, or dismissed her request for attention, despite her pressing the buzzer and asking. So she was aware that nothing was recorded and was concerned that there was no entry for this time period.
21. We looked at the events of 11 January. The records confirm Mrs C was reviewed by a member of the trauma and orthopaedic team at 10:08am. Observations of her vital signs were done (blood pressure, pulse, temperature, respiratory rate, oxygen blood saturations.) Her blood pressure was high, but other measurements were within normal range. The clinician noted ‘feeling well today, some slight lumbar backache secondary to lying in bed. Chest is better… Chest clear on examination.’ (‘The chest feeling better’ refers to the fact that she had been wheezing. We did not see anything in the records that Mrs C had complained about chest pain prior to this.)
22. A physiotherapist then saw Mrs C at 3pm. She declined to take part in therapy; after sitting out for two hours, she has just got back into bed and did not want to get up again. The physiotherapist demonstrated some bed exercises.
23. Mrs C’s observations were done and largely within normal ranges, with her blood pressure having come down. Her blood oxygen level was lower than normal at 93%, but because of her COPD, the target range in her case was between 88% and 92%, so this was a little over that range. An early warning score was calculated at 1. The NEWS2 guidance says a score of between 0 and 3 is deemed to be low risk and does not require a medical review.
24. Mrs C was then seen by a nurse, who made a note at 3:29pm. The nurse noted the latest observations and did not record any mention of chest pain or discomfort. This was the last record before Mrs C’s final phone call to her daughter.
25. We consider that up to this point, Mrs C was appropriately monitored. Our adviser said there was no indication that she was seriously unwell and she would not have needed closer monitoring. We saw nothing in the records to this point which suggested Mrs C was at risk of deterioration.
26. The NEWS2 guidance recommends that if they score between 1 and 4, patients should be monitored with observations every 4–6 hours unless more or less frequent monitoring is considered appropriate by a competent clinical decision maker. Mrs C’s NEWS2 did not go above 4 throughout her admission. Our adviser saw no indication that more frequent observation would be required. Her next observations would have been due after 7pm.
27. After her last phone call with her daughter (and while Miss C was on her way to hospital), Mrs C was seen by a nursing assistant. He recorded that this was just before 6pm. He noticed she was holding her chest and she said she had pains going right across her chest. Mrs C told the nursing assistant she had had them before but this time it was worse. He notified a nurse and they decided to do an ECG (electrocardiogram; a test which tests the heart’s rate, rhythm and electrical activity). While he was preparing this, Mrs C became unresponsive and the call was made to the emergency team, who started resuscitation. (The resuscitation and subsequent care were not part of our investigation.)
28. The crux of the matter is what happened in the time between the nurse’s assessment at around 3.30pm and the nursing assistant finding Mrs C with chest pain at just before 6pm. Any reports of chest pain would need to be acted on quickly. The NMC Code says nursing staff should ‘make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay’.
29. We consider Miss C’s description of her phone call with her mother is compelling; we have no reason to believe it is anything other than an accurate description of what they spoke about. This is also supported by the fact that at around 8pm, a clinician noted that Miss C told him her mother had called her that afternoon saying she had chest pain and no-one was listening. This is consistent with the account Miss C has given throughout the complaints process.
30. We recognise that there is no further evidence to say exactly what happened. For example, exactly when Mrs C tried to raise the matter, with whom and what each member of staff understood to be her situation.
31. There is no guidance or standards to say how quickly buzzer are responded to and their use is not recorded. It is not possible to say why a buzzer might not be responded to. Therefore we cannot say how often Mrs C tried the buzzer (other than when she used it while she was speaking to her daughter). We cannot say what nursing staff were doing at the time which resulted in them not attending to Mrs C. The patient’s use of the buzzer does not indicate the seriousness of their problem and patients use them frequently for a wide variety of reasons, many of which are not urgent. We cannot say what other priorities staff had at the time. The Trust’s investigation found that staffing levels were appropriate at the time, although we appreciate Miss C may not agree with this.
32. For the Trust complaint investigation, the Ward Matron reviewed the records and took statements from staff who were on the ward at the time. This is in line with the NHS Complaint Standards, which say that investigations should include staff interviews and statements was part of the evidence gathering as well as information from the records. This was an appropriate attempt to find additional information to help understand what happened.
33. No members of staff could recall Mrs C asking for help or mentioning chest pain. We can see why this would be frustrating for Miss C given her mother had told her she had tried to get staff’s attention. However, the Trust acknowledgment that it was possible Mrs C did try to do so and that if that was the case and nobody has responded (either to verbal request for attention or buzzer).
34. The Trust explained what action had been taken to improve its and to report it; in line with the hospital governance processes, this incident was discussed at the Trust’s Incident Safety Panel in January 2024 (chaired by the Associate Medical Director for Governance and attended by an MDT including members representing the ward team, Emergency Assessment and Access Clinical Service Unit, Trauma & Orthopaedic service and governance team.) It was agreed that a High Impact Learning Assessment (HILA) was required along with a Structured Judgement Review (SJR) to understand the events leading up to Mrs C’s cardiac arrest and subsequent death. The Trust’s Patient Safety Incident Response and Learning Panel (PSIRL) panel approved the plan. On 12 February 2024 a further discussion took place at the Trust’s Incident Safety Panel to review the HILA findings and the SJR outcome.
35. We realise Miss C will continue to be frustrated by what she considers to be a lack of accountability and she does not believe the Trust has accepted its failures contributed to her mother’s death. Even if no failures are identified, it is good practice for an organisation to seek improvement. We consider the Trust’s complaints investigation was in line with the NHS Complaint Standards.
36. Miss C was concerned that her mother’s aspirin (which she was already taking before her hospital admission) was not restarted after her operation. The purpose of the long-term low-dose aspirin would be to reduce Mrs C’s risk of having a heart attack or stroke. The Trust acknowledged it was a mistake to omit it.
37. We looked at an article called ‘Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials’ published in 2009. This says if a person has had a heart attack or coronary event, aspirin changes the chance of getting another event in the next year from 5.3% to 4.3% (a reduction of 1% over one year). This is relevant when referring to a large number of patients over a year. For one patient, missing out for a few days makes no statistical difference. It is a treatment aiming for long-term impact. The SJR came to similar conclusions; it should have been restarted, but it made no difference. We can see why Miss C is concerned that this error is symptomatic of poor care her mother received. We can at least reassure her that it was of minimal significance to what happened. It is a treatment aimed at providing a long-term impact.
Summary
38. We recognise that Miss C will continue to be frustrated. We have been unable to find further evidence of what happened in those hours leading up to her mother’s cardiac arrest. The Trust’s investigation went as far as we could reasonably expect in trying to find out and as such, we do not uphold the complaint.