Discharge on 1 April 2022
16. Mr N says his wife was too unwell to leave the Hospital on 1 April 2022 and was experiencing hallucinations. He recalled that a consultant said she should remain in the Hospital, but the next day doctors decided to send her home.
17. The Discharge Guidance explains that people should not remain in hospital if not clinically indicated. This reduces exposure to risks to the patient from hospital-acquired infections, falls and loss of function. It aims to achieve more independence for people and to maximise the availability of hospital beds. It contains a list of criteria for people to remain in Hospital.
18. The clinical records show that nurses considered Mrs N’s observations were stable. They did not record any concerns and noted she was ‘oriented to time and place’ which did not indicate she was confused. We have seen no reference to any hallucinations on 1 April 2023 or the day before.
19. The Medical Adviser told us Mrs N did not meet any of the criteria set out in the Discharge Guidance for someone to remain in hospital. She was noted to be feeling better and there did not appear to be any reason to make a clinical exception.
20. We recognise Mr N has a different recollection and that he believes his wife should have remained in the Hospital. We have seen no independent evidence to support this. We find clinicians followed the Discharge Guidance when they discharged Mrs N from the Hospital on 1 April 2022.
Femoral line
21. Mr N says doctors discharged his wife with a cannula still inserted in her right groin. He said clinicians had three opportunities to remove it and did not do so. He said his wife pulled it out herself and had to be rushed to hospital because of the bleeding.
22. The Infection Control Quality Standard says service providers should ensure systems and facilities are in place to enable staff to complete specified procedures necessary for the safe insertion and maintenance of a vascular access device and its removal as soon as it is no longer needed, in order to minimise infection.
23. The clinical records show clinicians inserted the femoral catheter on 29 March 2022. The reason for the catheter was to allow for haemodialysis to start. At that time it was not possible to insert a permanent catheter because Mrs N could not lie flat.
24. The Nursing Adviser said the line would not have been touched by nurses on the ward. It was used to start haemodialysis but should have been removed when the permanent line was in place from 1 April 2022. Renal nurses should have escalated the fact that the femoral catheter was still in place when Mrs N had her haemodialysis over the following days. They did not do so.
25. The Medical Adviser agreed that clinicians should have removed the femoral line on 1 April 2022. This should have been removed by an appropriately qualified healthcare professional once it was no longer needed.
26. Mr N recalled that his wife experienced extensive bleeding when his wife removed the femoral catheter on 7 April 2022.
27. We asked the Medical Adviser to explain whether Mrs N experienced any significant consequences from the incident with the femoral line. They explained how there are three types of complications that can arise from a using a femoral line.
28. The first type of complication is mechanical and relates to damage to the surrounding structures, such as veins or nerves. These would usually be apparent immediately or fairly soon after the line insertion. In this case the line was not close to any abdominal structures and could not have contributed to the perforation Mrs N later experienced. There is nothing to suggest there was any complication of this type.
29. The second complication is infection. There was no evidence of any infection around the site of the femoral line. This would be pain, redness, swelling or signs of a blood infection (septicaemia). The third type of complication is a blood clot in the femoral vein. There is no evidence Mrs N had this complication either.
30. The clinical records do not suggest Mrs N experienced any complications from the line remaining in place longer than needed. Clearly, there was bleeding when the line came out. This may have been more significant than would have been the case if a healthcare professional had removed the line. But there is no suggestion that the loss of blood caused any significant problems. Hospital staff would have corrected this problem when Mrs N returned there.
31. We find clinicians fell below the Infection Control Quality Standard when they did not remove Mrs N’s femoral line on 1 April 2022 or on the occasions when she attended the haemodialysis clinic on 2 and 5 April. This led to her experiencing bleeding that may have been avoided. We cannot say it had any lasting effect on her health. But we can see this must have been distressing for Mrs N and her family.
32. The Trust has already accepted this failing and offered sincere apologies to Mr N. It explained how it has changed procedures to ensure that checks are in place to avoid other patients having the same experience. We are satisfied the Trust has taken appropriate action in this respect. We do not consider it needs to do anything further.
Fall
33. Mr N says his wife fell on 22 April 2022, which he considers should have been prevented. He says this happened on the ward and not in the bathroom as the Trust has suggested. He believes she suffered a back injury that was not treated. He believes the Trust tried to cover up what happened during the incident.
34. The Falls Guideline says healthcare professionals should ask older people in their care about any falls in the past year. They should offer anyone who has fallen in the past year or has abnormal balance or gait a multifactorial assessment. This is a review of a person’s risk factors for falling. An appropriate healthcare professional or team should undertake the assessment if necessary.
35. The Falls Quality Standard says healthcare professionals should check people for signs and symptoms of fracture after a fall and should arrange a medical examination.
36. Nurses on the ward completed daily falls risk assessments. This involved calculating a risk score. People who scored ten or less were considered at low risk of falling, those who scored twenty or less were at medium risk and those who scored more were at high risk. Depending on the score nurses were instructed to take actions to reduce the risk of the patient falling. In this case Mrs N’s score was either nine or ten up to the date of her fall. This meant she had a low risk of falling and did not need support when mobilising.
37. The Nursing Adviser told us nurses regularly assessed Mrs N’s risk of falling. Mrs N had no history of falls before the admission, was independently mobile, alert, continent and had no sensory impairment. She did have broken sleep and took multiple medications which gave her a risk score of ten. We consider her falls risk was managed in line with the Falls Guideline.
38. At 10.45am on 22 April 2022 a nurse noted Mrs N ‘fell while walking back from the toilet.’ Mrs N said she had ‘banged her head.’ The nurse noted a doctor examined Mrs N and found no injury. Mrs N walked back to her bed using a Zimmer frame.
39. At 11.15am a junior doctor made a record of their examination of Mrs N following her fall. They included an account from Mrs N who explained how she had felt dizzy when standing from the toilet. She said her legs gave way and she had hit her head hard on the bathroom floor. This was heard by other patients on the ward. Mrs N had pain at the back of her head but said she did not have any spinal pain.
40. The junior doctor examined Mrs N and noted observations such as the levels of oxygen in her blood, breathing rate, blood pressure and levels of consciousness. They noted there was no evidence of bleeding or bruising at the back of her head and there her spine was not tender.
41. The Medical Adviser said the junior doctor’s record of their examination of Mrs N after her fall was comprehensive. It clearly shows there was no sign of any significant injury after the fall.
42. The records show the nurse and the doctor followed the Falls Quality Standard when they attended to Mrs N after her fall.
43. The Trust investigated the incident on 25 April 2022. They noted another patient had shouted out that someone in the toilet needed help. A nurse then found Mrs N on the floor on her way back to bed. Mrs N was able to move back to her bed without support.
44. There is a discrepancy about whether Mrs N fell in the bathroom or on the way back to her bed. At this point it is impossible to establish the exact location. The fall was not witnessed, and the clinicians would have been reliant on what Mrs N told them. In any case, neither clinician found any evidence that Mrs N had a significant injury when they reviewed her shortly afterwards. We can see no evidence Mrs N complained about back pain after her fall. There is nothing to suggest the Trust was trying to ‘cover up’ what had happened in its complaint response.
45. We find clinicians followed the relevant standards and guidelines when assessing Mrs N’s risk of falling and when responding to her fall on 22 April 2022. We appreciate how upsetting it must have been for her family when they found out she had fallen. There is no indication that clinicians missed any internal injuries. We have seen no evidence that clinicians should have done more to prevent her fall or that they did not respond to her appropriately afterwards.
Colonoscopy
46. Mr N says his wife had a colonoscopy on 27 April 2022. During the procedure she asked them to stop because she was in pain. He believes the colonoscopy caused internal damage and left his wife in pain for several days afterwards.
47. Good Medical Practice says doctors must provide a good standard of care. This includes providing safe and effective care. It says doctors must be competent in all aspects of their work.
48. The consultant who carried out the colonoscopy documented their account of the procedure. They said the examination was limited by Mrs N’s discomfort. The consultant noted ‘significant discomfort experienced several times with some distress.’ They did not consider this to be an adverse event and did not indicate the procedure caused any damage. There is no reference in the clinical records to Mrs N describing any pain over the following days. On 29 April 2022 she said she had no abdominal pain, felt well and had no complaints.
49. The Medical Adviser explained that a spontaneous perforation means the perforation happened naturally without any intervention. CT scans after the colonoscopy did not show any signs of perforation. On 11 May 2022 there were inflammatory changes suggestive of colitis and Mrs N developed the perforation on 14 May. Perforation is a recognised complication of a colonoscopy, but it was not the cause in this case. If it had been present it would have been clear on the scan from 11 May.
50. We find the consultant who carried out the colonoscopy followed Good Medical Practice. There is no evidence they were not competent at the procedure or that they did not provide safe and effective care. Clearly, the procedure was painful for Mrs N, and this has been upsetting for her family. We cannot say what happened fell below the relevant standards.
Food and tablets
51. Mr N says nurses on the ward left food and tablets on the table and his wife did not touch them. He says nurses did not give her any encouragement or assistance. He recalled an occasion when a nurse left tablets on the table when he was present. He asked if his wife should take all the tablets, and a nurse said she should.
52. The NMC Code says nurses must make sure they deliver the fundamentals of care effectively. This includes those receiving care have adequate access to food and drink and making sure they help those who cannot eat and drink without assistance.
53. The Nursing Adviser said nurses should observe the patient taking their tablets. They should only sign medicine administration charts when they have witnessed tablets being taken. They should not leave tablets on the patient’s table.
54. The records do not contain any reference to food and medication being left untouched on Mrs N’s table. There are references to Mrs N refusing to take medication on occasions because of nausea or drowsiness. Usually this would mean the medication was taken away rather than being left with the patient.
55. The Trust has accepted Mr N’s account about medication and apologised that tablets were left out when his wife was confused. It explained how it had arranged additional training for staff about caring for people with delirium and this included a section on managing medication.
56. The records clearly show Mrs N could eat independently without assistance. She had a poor appetite and there is evidence nurses encouraged her at times. The Nursing Adviser said it could be argued that nurses gave Mrs N a longer time to eat her meals rather than just leaving the food. We cannot say this meant nurses fell below the standard expected in the NMC Code.
57. We find nurses fell below the standard expected when they did not ensure Mrs N took all her medication. But we cannot say the issue relating to food was below that standard. There is no evidence the issue relating to medication had any impact on Mrs N. The deterioration in her health was unrelated to this issue. But we appreciate these episodes were upsetting for her family.
58. We are satisfied the Trust has taken appropriate action relating to medication. It has already apologised to Mr N and explained how there has been learning from his complaint.
Syringe driver
59. Mr N said he was led to believe palliative care would start immediately. However, there were no syringe drivers available, so his wife was left in pain for several hours.
60. The NMC Code says nurses must accurately identify, observe and assess signs of normal or worsening health in the person receiving care. They should make referrals to other practitioners when any action, care or treatment is required. They should seek help from a suitably qualified professional to carry out any action or procedure that is beyond the limits of their competence.
61. The End of Life Guideline explains how clinicians should use medication to manage a person’s symptoms as they approach the end of their life. It says there should be a review of current medication when a patient was established to be at the end of their life. Clinicians should consider using a syringe driver to deliver medicines for continuous symptom control if more than three doses of ‘as required’ medicines have been given in the past 24 hours.
62. The clinical records show doctors established Mrs N was reaching the end of her life around 3.30pm on 14 May 2022. A doctor and a critical care nurse reviewed Mrs N at that time. This included a medication review. They decided to prescribe medication for pain relief (oxycodone) and agitation (midazolam) to be given ‘as required.’ There was no indication that Mrs N was reaching the end of her life before that time.
63. Medication charts show that clinicians administered oxycodone to Mrs N at 3.40pm, 4.00pm, 6.00pm and 9.00pm. They also gave her midazolam at 4.00pm, 5.00pm, 6.00pm, 7.00pm and 9.00pm.
64. The critical care nurse reviewed Mrs N again at 6.06pm. They noted she was comfortable but had some signs of distress. They suggested medication should be kept under review. At 8.00pm a nurse noted Mrs N was comfortable, so did not request any further medication at that point.
65. Mrs N’s family approached a junior doctor at 10.00pm to ask about starting a syringe driver. At that point Mrs N was agitated. The doctor considered Mrs N had already had appropriate ‘as required’ pain relief, with five doses each of oxycodone and midazolam. However, they agreed she appeared to be still agitated and in pain. The doctor had a discussion with a senior colleague who agreed that a syringe driver should start. They arranged for an immediate injection of oxycodone before starting the driver, which began ten minutes later. The syringe driver contained alfentanil (for pain) and midazolam.
66. The Nursing Adviser told us nurses cannot administer pain relief until a doctor prescribes it. This would include setting up a syringe driver. The evidence suggests nurses were regularly monitoring Mrs N’s pain and agitation. When necessary they sought help from doctors. The evidence shows nurses followed the NMC Code.
67. The Medical Adviser said doctors followed the End of Life Guideline. When it became apparent that ‘as required’ medication was not having the desired effect they agreed to set up a syringe driver and this was in place a few minutes after they wrote the prescription.
68. We can see that nurses and doctors were regularly observing Mrs N on 14 May 2022. The End of Life Guideline suggests they should have arranged for the syringe driver to start around 6pm. However, the medication they gave ‘as required’ was comparable to what would have been used in the syringe driver. We cannot say that what happened fell so far below the relevant standard as to amount to a failing. Clearly, Mrs N was in pain and distress at times before the syringe driver started. This must have been incredibly distressing for her family. We cannot say she experienced these problems because of any failings by doctors and nurses at the Hospital.
Conclusion
69. We can see that Mrs N’s illness was distressing for her family and that she experienced pain and distress towards the end of her life. We have seen there were some failings in care, but do not consider these could have contributed to her death.
70. The Trust has already recognised there were failings about leaving a catheter in place and not ensuring Mrs N took all her medication. It has apologised for the distress these issues caused. It has also taken action to ensure there has been learning from what happened. We are satisfied with the action the Trust has taken.
71. We recognise Mr N and his family have strong views about what happened during his wife’s admissions to the Hospital. We hope they are reassured that we have seen no evidence of failings in care that could have had any significant effect on Mrs N’ health.
72. We do not uphold Mr N’s complaint.