DNACPR 20. Miss N complains the Trust failed to gain hers or her mother’s consent when implementing a DNACPR order on 19 June. She said across the admission there wasn’t one conversation with her mother about DNACPR, and the discussions held about initial concerns related only to the first night of the admission and were no longer of concern.
21. NICE CG115 says when people with COPD are started on NIV, there should be a plan covering what to do in the event of deterioration, and ceilings of therapy should be agreed. We find records made on Mrs N’s admission on 19 June show the Trust adhered to this guidance.
22. Resuscitation Council guidance says it is not necessary to obtain the consent of a patient or family member in completing the DNACPR form or in making this decision. This guidance says the overall clinical responsibility for decisions about DNACPR rests with the most senior clinician responsible for the person’s care. The Trust acted in line with this guidance, as for Mrs N, this decision was made by the treating doctor.
23. GMC guidance on CPR also applies. This guidance says when a patient is admitted to hospital acutely unwell or becomes clinically unstable in their home and are at foreseeable risk of cardiac or respiratory arrest, a judgement about the likely success of CPR should be made as early as possible.
24. The guidance says reasonable efforts to discuss a patient’s CPR status should be made with the healthcare team and those close to the patient. Records on 19 June show discussions of this nature between the relevant clinical staff, as well as with Miss N. We are satisfied the evidence shows this guidance was met.
25. Our respiratory adviser explains the most important factor when making any DNACPR decision is about ensuring the correct clinical outcome. It is about ensuring a clinically-led decision is made appropriately, in the best interests of the patient, considering their clinical circumstance. Our respiratory adviser explains it is about communication, rather than consent.
26. We know Miss N is concerned because she felt the concerns raised with her during that discussion only applied to her mother’s circumstance when she first went into hospital. The DNACPR decision remained in place and is documented throughout the admission. During this time, Mrs N was seen by various healthcare professionals including nurses, junior doctors, and senior doctors from across different specialties. There is no record of any objection raised about the DNACPR decision and ongoing implementation by any other healthcare professional involved in Mrs N’s care.
27. Whilst Mrs N may have become more stable for some time following her admission, she was diagnosed with chronic hypercapnic respiratory failure and it was determined she would be for long-term NIV. Our respiratory adviser says the rationale on which the DNACPR decision was based remained applicable throughout the admission. We acknowledge Miss N’s concern and hope to assure her that we do not find evidence of service failure or breach of the relevant guidance.
Heart failure 28. Miss N complains that the Trust failed to appropriately treat her mother’s heart failure. We hope to assure her the Trust provided appropriate treatment, in line with guidance.
29. Records show Mrs N had two pre-admission cardiac disease states (conditions affecting the function of the heart). These were cardiac arrhythmias (abnormal heart rate or rhythm) and cor pulmonale (pulmonary heart disease, an enlargement of the right ventricle of the heart). Our cardiology adviser explains these are typically associated with chronic respiratory disease.
30. The primary issues on Mrs N’s admission were respiratory issues, and heart failure was not her primary diagnosis. Appropriately, the Trust’s clinical focus was on Mrs N’s primary – respiratory - problems. That said, records show the Trust considered her heart in taking decisions to treat her respiratory issues and infection, and this is evidenced by the fluid balance.
31. Our cardiology adviser says in an acute hospital setting, in the context of these other primary respiratory issues, appropriate treatment for heart failure is with the balance of fluids. This can mean either in restricting fluids to reduce fluid overload, or in giving diuretics (commonly known as water tablets) to increase urine production and avoid pulmonary oedema (a build-up of excess fluid in the lungs).
32. As Cosentino et al.’s study explains, fluid retention is a major determinant (cause or factor) of symptoms in patients with heart failure. For this reason, the study says the first strategy in managing heart failure patients is to optimise fluid balance. Importantly, the study explains this being very complex, as the heart, kidneys and lungs are all deeply involved in fluid volume regulation.
33. Our cardiology adviser explains there is no specific guidance for this. It is a case of clinical judgement, in making best attempts to manage the balance between too much fluid causing overload which would impact respiratory and cardiac function, and too little fluid causing dehydration which would have made infection worse.
34. Our cardiology adviser explains there is not any single test that can be performed to say whether patient has heart failure or not. Records show Mrs N had the appropriate examinations to check what her diuretic and fluid requirements were, and her fluid was balanced accordingly, with input gained from the cardiology team. Our cardiology adviser confirms the appropriate steps were taken in line with this appropriate clinical approach.
35. Miss N is specifically concerned that the Trust took only one ECG which is noted as of poor quality, and it did not repeat or take any further ECG. Our cardiology adviser explains there is no clinical standard or guidance to say someone with the set of symptoms Mrs N had should have an ECG. As her primary concern was respiratory, the management plan was appropriately focused here. A decision to take an ECG in this circumstance is down to clinical judgement, and records show one was taken.
36. Our cardiology adviser explains the main purpose of taking an ECG in this circumstance is to look to exclude any haemodynamically compromising arrhythmia (abnormal heart rate or rhythm that would cause an abnormal or unstable blood flow).
37. Whilst we acknowledge notes are made about its quality, the ECG taken here was at Mrs N’s bedside, with a mobile machine. Whilst an appropriate method of taking an ECG, these are known to be less high quality than from a permanent and fixed ECG machine. That said, our cardiology adviser has reviewed the ECG taken and confirms it was of adequate quality and sufficiently readable for the clinical team to exclude any major arrhythmia, when combined with Mrs N’s observations.
38. We find the ECG was therefore of a sufficient standard to perform its purpose. We do not see any clinical need at any later time to suggest ECG should have been repeated. Our cardiology adviser said ECG was only needed for this purpose, as such the ECG that was taken fulfilled that purpose.
39. Miss N complains the Trust failed to take an echocardiogram (ECHO). We can see in its response to the complaint, the Trust has already appropriately acknowledged the confusion that ECHO was initially discussed and requested but was not done.
40. Our cardiology adviser says there is no clinical standard or guidance to say someone with the set of symptoms Mrs N had should have an ECHO, and again this was down to clinical judgement. Our cardiology adviser explains the purpose of an ECHO in this circumstance is to look at the left ventricular ejection fraction (how much blood is being pumped out of the heart with each contraction).
41. Had an ECHO been performed, whether this had shown a poor, moderate or good ejection fraction, it would not have had any impact upon Mrs N’s management plan. This is because the appropriate treatment for any heart failure in Mrs N’s case was to optimise fluid balance, irrespective of her ejection fraction.
42. There is ample evidence to show this process was being followed and fluid was being balanced by the clinical team, throughout Mrs N’s admission. We do not consider it a service failure that an ECHO was not taken, because we do not see it would have made any difference or had any clinical bearing on Mrs N’s management or treatment.
43. Miss N also complains of a lack of cardiology input, that the respiratory team spoke to a cardiac specialist just once. As we have explained, Mrs N’s primary clinical problems were respiratory, and any heart failure was an associated secondary occurrence from her chronic and now acute respiratory conditions. There is plenty of evidence to show Mrs N received senior medical input throughout her admission, including having consultant-led ward rounds (daily clinical reviews).
44. It is not a reasonable expectation for every patient to be seen by, or for their care to involve, input from a consultant from each specialty that may form a part of their clinical picture. Just as it is reasonable to expect any competent cardiologist to treat a chest infection alongside any primary cardiac issue in their patient, it is reasonable to expect any competent respiratory consultant can manage and treat heart failure in the context presented here.
45. That said, it was appropriate that cardiology input was sought. This was in line with GMC good medical practice guidance which says clinicians must 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.
46. Records show the respiratory team obtained referred to and obtained advice from cardiology specialists, and their advice this aligned with the ongoing management plan already in place. Considering Mrs N’s presentation, there was no requirement for earlier or repeated cardiology input into her care for the reasons explained.
Atelectasis 47. Our respiratory adviser explains atelectasis is a medical term that can describe a variety of differing circumstances, with differing severities. Whilst it can mean a full collapse of a lung, it can also describe small areas of mucus impaction (build-up), or small scars within the lung (where the lung may not be able to fully expand but on a much minor scale to that of full collapse).
48. It does not always involve the same amount of lung tissue, and the amount varies depending on the source. It typically results in breathing difficulties and reduced oxygen in the lungs, especially where lung disease already exists.
49. The atelectasis noted in Mrs N’s records is from the chest X-ray taken on 4 July. The X-ray reports: ‘Bilateral pleural effusions larger on the left with adjacent atelectasis’. Our respiratory adviser explains this type of atelectasis is the result of compression of the lung because of the fluid below (pleural effusion), and it is not significant clinically in the manner that a lung collapse would be.
50. Considering Mrs N’s past medical history and her clinical problems during this admission, this type of atelectasis is not an unexpected finding within this chest X-ray. Our respiratory adviser explains the fact it was noted alongside various other respiratory issues also seen, suggests it was a result of the impact of her chronic illnesses and infection.
51. Miss N complains the Trust failed to appropriately treat her mother’s atelectasis. Our respiratory adviser explains there is no specific guidance on treatment, as atelectasis is managed and treated based on its aetiology (cause). Yet, we can assure her we find appropriate management and treatment was given.
52. Mrs N had various considerable respiratory illnesses, all of which impacted her respiration. The day after admission she was diagnosed with chronic hypercapnic respiratory failure, and she was considered to have heart failure. Our respiratory adviser explains treating heart failure with fluid balance, as the Trust was doing, usually results in improvement of pleural effusion and in turn, the type of atelectasis Mrs N had.
53. Records also show that Mrs N was being given antibiotics, nebulisers and physiotherapy to treat infection. Our respiratory adviser says this is a reasonable approach to treat an infection-related atelectasis. They say ventilation therapy is often given as additional treatment, and Mrs N was already receiving this via NIV.
54. We therefore find evidence to show Mrs N was receiving appropriate treatment and management for this finding of atelectasis, within her overarching management and treatment plan.
Care given 31 July – 2 August 55. We know how strongly Miss N feels that there was a lack of appropriate care given to her mother between the dates of 31 July to 2 August. We have considered all records covering this period carefully, and hope to assure her we find the clinical care provided was appropriate.
56. Over the three-day period in question, records show Mrs N received input from the following roles/specialisms: junior doctor, clinical fellow, respiratory consultants, physiotherapists, hospital chaplain, infection prevention and control/tissue viability specialist nurses, staff nurse, pulmonary nurse practitioner, microbiology, registered nurses and nurse practitioners.
57. Miss N raised several specific concerns for why she feels her mother did not receive appropriate care. We have considered, and address, each one in turn.
58. Her mother could no longer stand – Records show a lengthy physiotherapy assessment took place on 31 July. The physiotherapist documented that Mrs N said she had not been mobilising due to confidence and having a fear of falling. Any impact upon her ability to mobilise during this period does not appear to be the result of any apparent clinical deterioration. She was offered daily physiotherapy treatment across this period, and we consider this aspect of her care was appropriate.
59. She had audible bilateral lung crackles – Mrs N had known bronchiectasis, which our respiratory adviser explains causes audible lung crackles whether there is an active infection present or not. She was also considered to have heart failure, which can also cause lung crackles. This finding did not indicate anything new or acute for the days in question, nor required any additional or alternative care to that already being given.
60. Her mother had significantly low blood pressure – Whilst Mrs N’s blood pressure was lowered, our respiratory adviser says it was not at a level that would be clinically significant for her, as her condition and diagnoses can have this impact. In addition, NIV and the treatment Mrs N was receiving for heart failure is known to lower blood pressure. Our respiratory adviser explains this was all accounted for within the management plan in place, and did not indicate anything new or acute nor required any additional or alternative care.
61. She had raised CRP levels – These levels were not significantly raised nor significantly changed to indicate any acute change in Mrs N’s condition during this period, to have required any additional or alternative care to that already given.
62. Miss N raises concern about her mother’s care over these three days because she says the Trust failed to identify her mother’s chest infection and only gave antibiotics for cellulitis. Our respiratory adviser agrees with the Trust’s view, that the clinical findings suggested heart failure without superadded (additional) chest infection.
63. Our respiratory adviser says Mrs N’s clinical status between 31 July and 2 August did not suggest any new or acute event – one that quickly becomes very severe – or any significant change that was not already being managed within the clinical care and treatment plan. They explain the three chest X-rays taken in July show more evidence of worsening heart failure than of chest infection.
64. When comparing the X-rays, these show stable findings which would not indicate any concerning chest infection. There was no significant change in infection markers and the slight rise seen in CRP levels was reasonably put down to worsening cellulitis, as seen on examination.
65. Miss N also raises concern that antibiotics were given after considerable delay. We hope to assure her we find no delay in this treatment provision. On 1 August, the plan for clarithromycin was documented at 11.47am, it was ordered within half an hour and the first dose given one hour after that. NICE NG141 recommends offering antibiotics but does not state a timeframe when they must be started. Our respiratory adviser considers this action was prompt and timely.
66. NICE 138 and BNF guidance recommends giving clarithromycin twice daily. Records show the Trust followed this as Mrs N received two doses on 1 August. Our respiratory adviser explains there is no need for this to be given at strict, specific times, that it is usually given once in the morning and once in the evening. We find the timing of the two doses Mrs N received on 1 August were appropriate and in line with guidance.
67. She then, appropriately, received her morning dose of clarithromycin on 2 August. During that day the plan was for discussion with microbiology, and they advised changing the antibiotic type to teicoplanin. NICE NG138 and BNF guidance also recommends giving teicoplanin twice daily. This was prescribed, ordered and records document Mrs N received her first dose that evening.
68. Our respiratory adviser confirms there is no evidence of delay. Although records on 2 August note to ‘stop’ clarithromycin, this simply meant further doses were not to be given. Mrs N remained under antibiotic cover during the day on 2 August having received her morning dose. Guidance recommends twice-daily administration of both types of antibiotics, and records show the Trust adhered to this. We do not see evidence of any delay as is alleged.
69. From the recorded evidence of the period in question, we do not find anything to suggest the Trust failed in its care and treatment, or that Mrs N required any additional input or treatment to that already given.
70. We hope to assure Miss N that, as explained within NHS website information, the antibiotic given to her mother was a type appropriate to treat chest infection in any event. Records show discussions were held with the microbiology team, a repeat blood test was taken and Mrs N continued to receive NIV. Our respiratory adviser confirms this was appropriate treatment for chest infection, even had this been indicated.
Events on 3 August 71. Miss N complains nursing staff removed her mother’s life-saving ventilation on the morning of 3 August without clinical reason and without calling for a doctor. She says the Sister took it upon herself to remove all equipment when her mother took a breath just minutes before the machines were removed.
72. At the time in question, Mrs N was on overnight NIV. An entry documented at 4.47am on 3 August notes Mrs N was having an unsettled night and had asked to be sat out in a chair. NIV was in place and there were no concerns with its delivery. NIV had been formally checked at 3am, with the next expected check to take place at 7am. Just short of one hour after sitting out, at 5.39am, Mrs N was found unresponsive with NIV still in situ.
73. Our nursing adviser explains the recording of spontaneous breaths on NIV show that Mrs N’s breathing became erratic suddenly at around 5.33am. Records show sporadic breaths were taken between 5.33am and 5.43am. Our nursing adviser says these were most likely agonal breaths.
74. As explained by Sudden Cardiac Arrest UK, agonal breaths are irregular, gasping breaths that happen when a person is dying. It is the body’s automatic reflex as the heart stops pumping adequate blood to the brain and vital organs. These sporadic breaths may persist for several minutes after someone loses consciousness. Whilst the chest may appear to rise and fall, it is not normal or life-sustaining breathing as it does not represent adequate oxygen intake.
75. Our nursing adviser says if nurses identified that life had ceased whilst NIV was in progress, they would be expected to prepare the body in line with NEoLCP guidance, which includes removing NIV.
76. Mrs N was found unresponsive, and she was not for resuscitation. She was moved back to be laid in bed and NIV was removed. We can assure Miss N the NIV chart shows nurses only removed the NIV after Mrs N had stopped breathing completely. The timing for removal was therefore appropriate and in line with NEoLCP guidance.
77. Records note that as is appropriate, the doctor was informed to attend and formally verify the death. As Mrs N was not for resuscitation, no further clinical intervention was indicated and as such there was no requirement for a doctor to first be called before the nurses took their appropriate actions on this morning.
In conclusion 78. We were very sorry to have learned of the reasons for Miss N’s complaint. It is clear how distressing these events must have been at the time, and we understand this upset has remained following Mrs N’s sad death in hospital.
79. From the recorded evidence and the clinical advice obtained, we find these aspects of Mrs N’s care were appropriate and given in line with the relevant nationally expected standards. We do not see any evidence of service failure. We hope our explanations and decision can give Miss N assurance of this.