Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We also look at whether there are signs the events complained about had a negative effect which the organisation has not put right.
We have considered whether there are any signs of failings regarding treatment for sepsis. We have not found any indications that any different treatment or action could have prevented Mr S’s deterioration.
Sepsis
15. Miss S says the Trust delayed investigating Mr S’s deterioration from 7 October, including screening for sepsis. She believes he died a few days later due to delays to diagnose and treat sepsis.
16. We understand it has been distressing for Mrs S to wonder if Mr S could have lived longer had sepsis treatment been started earlier. We are sincerely sorry for her family’s loss.
17. Sepsis is a life-threatening reaction to an infection. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs.
18. We reviewed this issue with the help of a geriatrician clinical adviser. After consideration, we cannot see any evidence to suggest different treatment options, such as treatment for sepsis, could have prevented Mr S’s death. We appreciate this was a distressing experience for Miss S and her family. We will now explain our decision.
19. We understand there was a delay for doctors to review Mr S due to being with other patients when the nurse first called them. The Trust says when Miss S raised concerns with the nurse about his symptoms, they escalated these concerns to a doctor. We understand the nurse also commented Mr S may just be having ‘an off day’, which we appreciate did not reassure the family and made them believe the nurse was not taking their concerns seriously. The nurse apologised for any distress this caused, and it was documented that she had tried to reassure the family.
20. The Trust acknowledged the nurse needed to call for the doctor on four different occasions as they were with other patients at the time. The doctor reviewed Mr S at 6pm due to needing to tend to other patients. By this time, his family members had left the ward.
21. GMC guidelines say doctors must give a good standard of practice and care. If they assess, diagnose or treat patients, they must:
• properly assess the patient’s condition, looking at their history (including their symptoms and psychological, spiritual, social and cultural factors), their views and values; and, where necessary, examine the patient • quickly give or arrange suitable advice, tests or treatment where necessary • and refer a patient to another practitioner when this would be better for the patient.
22. As we have already explained, we know the Trust recognised Mr S had interstitial lung disease. The NICE guidelines for this condition explains it is an incurable progressive condition for which symptoms are managed to promote comfort, such as with oxygen support which we understand Mr S had at home. Prognosis is on average 6-12 months from first diagnosis of the condition, though this will vary patient-by-patient.
23. It was also recorded in that this was a readmission for pneumonia, covid-19, exacerbation of ILD progression, and emphysema/pulmonary hypertension (causing breathing difficulties). Records show this followed an admission the previous month for treatment for disease progression, for which he was treated with antibiotics and prednisolone (a treatment to reduce inflammation and calms the immune system). We can see a clear medical history was taken to inform Mr S’s care, in line with the GMC guidelines.
24. Our geriatrician adviser notes that on 7 October, Mr S was more unwell. His NEWS (National Early Warning Score) was five but then improved to three during this time. NEWS is calculated based on the patient’s observations, which include pulse, temperature, blood pressure, and oxygen saturation and can range from a score of 0-20. A score of four and below indicates a low risk of deterioration, and five and above should trigger a ‘think sepsis’ approach. This is reflected in both the national and Trust’s local guidance.
25. We note that other medical conditions can elevate NEWS, such as in the case where Mr S’s pre-existing condition, interstitial lung disease, continued to progress. He also had a raised lactate which is not specific to infection or sepsis.
26. In response to Miss S’s concerns on 7 October, the nurse called for a doctor four times. As noted above, the doctor reviewed him at 6pm due to being with other patients at the time of the initial call. We are assured that the nurses repeat calls for a doctor to attend demonstrate they did take Mrs S’s concerns seriously.
27. We appreciate doctors must prioritise patients on clinical needs, and we do not have information available to us to know what needs other patients had at different times during Mr S’s admission. We understand doctors may be responding to medical emergencies at times, which the Trust has explained as a reason for some delays during Mr S’s admission.
28. We can see his NEWS continued to be monitored throughout his admission. On the 11 October his NEWS was three until 11.23am when it was reported as ten. It improved to a score of four when checked again shortly afterwards, but we understand Mr S continued to deteriorate. A doctor reviewed him and explained to his family that he was approaching the end of his life. We understand Mr S died very soon afterwards.
29. We understand Mr S had a post-mortem which determined his cause of death as ‘usual interstitial pneumonia’ (UIP). Our adviser explained this is not the same as what is known as ‘pneumonia’, which is typically due to infection. UIP is a form of interstitial lung disease which is characterised by progressive scarring of the lungs.
30. Our adviser explained that if the Trust had started treatment earlier for sepsis, the outcome would not be different. This is because UIP cannot be reversed with treatment, and it also will not always stop it worsening. We are assured sepsis treatment would have been unlikely to change the outcome.
31. This has understandably remained a deeply traumatic experience for the family. We are very sorry to hear they did not have more time to say goodbye to him because of his rapid deterioration.
Penicillin allergy
32. Mrs S says the Trust asked inappropriate questions about Mr S’s penicillin allergy. She says he had a known penicillin allergy and was wearing a wristband to make staff aware of this.
33. The Trust explained that the antibiotic they wanted to give him, meropenem, has a similar chemical structure to penicillin. This means patients can have a similar allergic reaction to it.
34. On 11 October, Mr S deteriorated. Staff believed this was due to possible sepsis. This was because blood test results that day indicated raised inflammatory markers and an acute kidney injury (AKI). A previous chest X-ray and urine test on 9 October were negative for infection markers.
35. When staff were exploring treatment options, they asked the family about the nature of Mr S's allergic reactions. They had already given Mr S two courses of levofloxacin (an antibiotic not related to penicillin) and wanted to try meropenem.
36. As there can be a similar allergic reaction to meropenem, and reactions can vary in severity, our adviser explained it was appropriate to ask the family for this information in line the GMC’s guidelines already mentioned. By asking the family about Mr S’s previous reactions to penicillin, the people who know Mr S best, they were able to decide promptly considering severity of risk, and weigh against possible benefit.
37. Sadly, Mr S further deteriorated before antibiotics could be started. The medical team decided to let him die peacefully surrounded with his family.
38. We appreciate his family felt this was an unfair burden on them to contribute to a decision which may have resulted in him suffering an allergic reaction. It also made them question the competency of the medical team. We are assured this discussion was appropriate to enable prompt decision-making about possible treatments for infection, in line with the GMC guidelines and known concerns about similar allergic reactions.
Oxygen
39. Miss S is concerned the Trust increased Mr S’s oxygen prescription too abruptly and too high from 6lt to 15lt on 11 October. She says this caused Mr S avoidable pain and discomfort, loss of dignity, and distress.
40. The Trust said Mr S’s observations showed his oxygen levels were stable until his deterioration on 11 October. It said it aimed to keep his oxygen levels at 88-92% due to the risk of hypercapnia (high levels of carbon dioxide in the blood) and respiratory failure from over-oxygenation.
41. We understand that when there is a sudden deterioration, the priority is to avoid a lack of oxygen to the brain (hypoxia). This is because brain cells can start to die within 30-60 seconds and irreversible brain damage can occur within three to five minutes. The priority is to ensure that the supply of oxygen to the brain is not interrupted. For this reason, the BTS guidelines recommend that for critically-ill patients, high-concentration oxygen should be administered immediately. This means a gradual increase would not be appropriate. Our geriatrician adviser explained in practice the medical team would correct hypoxia quickly and then gradually reduce the oxygen amount to maintain saturations to avoid over-oxygenation. This is done by monitoring arterial blood gasses or ‘ABGs’ (tests that measure oxygen and carbon dioxide in the blood). This is what the BTS guidelines say should happen.
42. Mr S’s oxygen levels were stable until his deterioration on 11 October. The doctors had difficulties with the ABG due to Mr S’s low pulse, but the respiratory physiotherapist managed to get a sample. Respiratory physiotherapists are particularly skilled at obtaining ABGs and it is one of their key responsibilities.
43. As the Trust explained, his oxygen saturations were at 88% when on 15 litres of oxygen, the highest amount of oxygen it can prescribe. This is in line with the BTS guideline which says patients with a known risk factor for hypercapnic respiratory failure should have a target saturation of 88-92%. He was noted to also have an abnormal breathing pattern (Cheyne-Stokes breathing), which is commonly seen when someone is approaching the end of their life. We can see doctors explained to his family that he was very unwell and likely to pass away imminently. We appreciate this was a very distressing experience for Mr S’s family.
44. We are unable to see any signs that anything went wrong when prescribing Mr S 15 litres of oxygen. We understand he was having breathing difficulties due to the deterioration of his condition, and it was necessary to rapidly increase his oxygen support to reduce the risk of brain damage in line with the BTS guidelines. We appreciate seeing Mr S struggling to breathe and appearing uncomfortable would have added to their distress at this already difficult time.
Pain management and maintaining dignity
45. Miss S says the Trust also delayed medication for oral thrush and pain, causing him pain and distress and contributing to his subsequent deterioration.
46. The Trust accepted there was a lack of documentation regarding Mr S’s general oral care. It says oral thrush was diagnosed on 9 October and treatment commenced, which is documented.
47. It said it would put this right by reminding all staff of the importance of oral care and ensuring all staff are up to date with mouthcare techniques.
48. Whilst we have seen a shortcoming with documentation, we have not seen a basis to suggest a failing in response. Furthermore, our geriatrician adviser says Mr S’s oral care did not cause his deterioration. As we have explored above, Mr S had a progressive condition which could not be cured. Our adviser notes mouthcare is an important part of end-of-life care, which will be considered later in this decision.
49. Regarding pain relief, the relevant guidelines are the core standards for pain management.
50. Mr S was able to communicate his symptoms which meant it was appropriate to take verbal pain scores (e.g. rating pain from 0-10). There is evidence his pain was regularly monitored in this way and recorded as 0. The nursing and medical notes mention Mr S had no complaints and was comfortable. Recording the pain score along with the patient’s observations is in line with the core standards for pain management, which explain the need to consider self-reporting and observation of the patient, including their body language, tone and words as well as clinical observations.
51. Our adviser noted that he was prescribed morphine to be taken as required (referred to as PRN). He was given doses every night between 2 and 5 October and on 9 and 10 October. They also explained morphine can be given for breathlessness as well as pain. It is not clear from the notes why it was given at the same time each night, but our adviser considered this may have been to aid sleep. He was also prescribed zopiclone which he took some nights, and he asked for it again when it was stopped which suggests he was struggling with sleep.
52. The Trust also believed some pain Mr S complained about on 11 October may have been due to constipation. This was the only day he reported pain, which coincided with not having had a bowel movement for a number of days. He accepted a laxative on 11 October and was given paracetamol through an IV drip. We recognise this was also the day Mr S’s family found him in wet bedsheets due to a deterioration in his health and mobility, preventing him from reaching his urine bottle which he was otherwise independent with.
53. We are assured that we cannot see any obvious signs that Mr S was experiencing avoidable pain.
54. It is important that pain and the patient’s family’s perception of pain is considered as part of end-of-life care considerations. We will explore now explore Miss S’s concerns that there may have been a delay in preparing the family for the end of his life.
End-of-life care
55. Miss S complains the Trust did not recognise Mr S was approaching the end of his life to inform the family in a timely manner. This resulted in a loss of opportunity for them to spend more time with him before he died.
56. The Trust says nurses escalated their concerns to a ward doctor as soon as they became aware that he was unwell. The doctor prescribed initial treatment, requested further investigations, and sought advice from senior colleagues. It explained the mortality rate for patients with Mr S’s condition was very high.
57. The Trust recognises communication could have been better with the family and has subsequently identified areas for improvement in documentation and communication with families. It says feedback has been shared with staff about this to ensure improvements are made.
58. Mr S had idiopathic pulmonary fibrosis (IPF). The NICE guideline for IPF says that the prognosis of this condition is 6-12 months after diagnosis. This should be discussed with patients in a sensitive manner and include information on the severity of their disease and average life expectancy, the varying course of the disease, and the management options available.
59. Due to limited information, we do not know how much of this information had previously been discussed with Mr S and his family, both at diagnosis and during subsequent consultations or hospital admissions. We know he was receiving oxygen at home to manage his symptoms, as per the IPF guideline to offer symptom relief with oxygen therapy.
60. We also understand Mr S had other recent hospital admissions and several episodes of sepsis in the lead up to this hospital admission. We can see on 2 October, Mr S self-reported feeling a decline in his abilities and loss of confidence in his ability to manage at home, despite being medically optimised for discharge home and his oxygen levels back to his baseline.
61. Our geriatrician adviser noted that this deterioration during the earlier hospital admission could have prompted an advanced care planning discussion, with a plan put in place about his wishes, as per the NICE end of life guidelines. This would likely have resulted in fewer investigations and treatments which caused distress, such as ABGs, cannulations, and high flow oxygen support. Instead, comfort could have been prioritised with palliative care, such as a focus on pain relief and mouth care.
62. We recognise, however, that many families understandably want attempts at life-saving treatment to continue even when these conversations take place. We understand Mr S’s family already felt not enough was being done and asked the medical team what more they were going to do to help him. The doctors told them they were doing all they could. We appreciate it would have been a difficult decision for the family to agree for active treatment to be stopped. As previously mentioned, our adviser told us that different or additional treatments would have been unlikely to change the outcome.
63. We also understand that Mr S deteriorated quite suddenly on the day he died. In the early morning his oxygen saturations were maintained on four litres of oxygen, his NEWS was stable, and he was independently mobile with minimal assistance needed with personal hygiene, continence care, and food and drink.
64. A few hours later, his NEWS had increased to 10 and his mobility had reduced to the extent that he had been unable to reach his urine bottle, resulting in incontinence and causing great concern for his family. Mr S has been independent with his continence needs until this time. The doctors reviewed him, increased his oxygen support and provided IV fluids, and discussions took place about different antibiotics to try. Despite some improvement in his observations, he continued to deteriorate.
65. We can see the Trust was actively treating Mr S at the time of his death. His deterioration was rapid. Whilst we know IPF has a poor prognosis, we have not reviewed Mr S’s full medical history from his diagnosis to know exactly what could be expected for him as an individual, how his illness progressed over time, nor what discussions he may have had with his medical team or his family about this. This is outside the scope of what we are considering here. We know he had a DNACPR (do not attempt resuscitation) decision in place which was noted to have expired and needed reviewing on 11 October, which suggests some discussions had previously taken place about resuscitation and his wishes. These conversations commonly take place when doctors recognise resuscitation may be ineffective due to the stage of a patient’s condition.
66. It is our view that Mr S became very unwell very quickly, resulting in limited opportunity to have a conversation earlier than the one that took place shortly before his death. Whilst we recognise advanced care planning may have been advisable during the previous hospital admission, we can see the family wanted active treatment to continue when they were told he was likely approaching the end of his life. This is undoubtedly a distressing experience for any family to be in when a loved one is gravely ill.
67. We appreciate the time Miss S has taken to explain her concerns and give us the opportunity to explore them. We hope we have reassured her that we have not seen signs that any decisions adversely impacted on Mr S’s chances of recovery. We are sincerely sorry for their loss.