Deterioration
17. Mrs E said when she read her father’s medical records, she found the Trust had not followed NEWS2 guidance regarding how regularly it had undertaken Mr N’s observations. Mrs E said the Trust also failed to notice that her father was not rousable and had spent a full day sleeping which was not normal for him. Mrs E feels if the Trust had recognised her father’s deterioration in a timely manner the outcome may have been different for him.
18. The Trust said the day before Mr N had died, it conducted observations and escalated Mr N’s care in line with NEWS2 guidance. The Trust said Mr N began to deteriorate during the morning on the day he died. The Trust said it commenced fluids, oxygen therapy and pain relief to stabilise Mr N’s condition.
19. NEWS2 is a tool used to detect clinical deterioration. It is a scoring system which allocates a score to a set of physiological measurements - breathing rate, oxygen saturation level, blood pressure, pulse, level of consciousness and temperature. A score is given to each parameter, depending on how far away it is from a ‘normal’ measurement, and the overall score is then calculated.
20. NEWS2 guidance says a score between one and four requires observations to be repeated within four to six hours. A score of five and above requires an urgent review by the doctor and observations repeated hourly. A score of seven and above is the highest escalation and requires an assessment by the critical care team.
21. NICE guidance on recognising deterioration says staff caring for patients should be competent in monitoring, measuring, interpreting and responding promptly to an acutely ill patient.
22. We have reviewed the NEWS2 scores for Mr N’s admission and we can see Mr N consistently scored between one and four until the day he died. A score of four and below means there is a low risk of clinical deterioration and observations can be repeated within four and six hours. Mr N had low blood pressure, which the Trust noted was normal for him, but it would consistently raise his NEWS2 score as it was not within normal parameters.
23. We understand Mrs E has raised concerns regarding the NEWS2 scores taken on the day before Mr N died. She is worried the Trust was not performing observations as often as it should.
24. On that day, we can see the Trust recorded Mr N had a NEWS2 score of two at 7.04am. This should have prompted observations at a minimum of four to six hourly. The Trust did not repeat Mr N’s observations for approximately eight hours, until 3.16pm, when his score was two.
25. Following this, Mr N’s observations were next repeated at 8.35pm, five hours later, where he had a NEWS2 score of two. We can see the Trust next repeated Mr N’s observations at 1.28am the following day, which was five hours later, and he had a score of two.
26. We acknowledge the NEWS2 observation taken at 3.16pm was two hours late to be performed. We appreciate this has caused worry and concern to Mrs E. We can see Mr N scored two due to having low blood pressure which the Trust noted was normal for him. As Mr N’s NEWS2 score had not changed when the Trust repeated the observations, we have not seen any clinical impact of the observations being taken two hours late.
27. Our adviser explained Mr N’s condition began to deteriorate on the day he died. We can see the following NEWS2 scores were taken on this date:
• 1.28am – score of two • 5.12am – score of two • 6.49am – score of four • 7.01am – score of eight
28. From the evidence we have seen so far, we can see the Trust acted in line with NEWS2 guidance in the observations it had taken that day. We can see Mr N scored two at 5.12am and in line with NEWS2 guidance his observations would not need to be repeated for a further four to six hours. We can see the Trust repeated Mr N’s NEWS2 scores at 6.49am where he had a NEWS2 score of four. This was earlier than the NEWS2 guidance suggested was necessary. We think this shows the Trust was actively monitoring Mr N and noticed a change in his condition as it repeated his NEWS2 scores within two hours.
29. Following the NEWS2 score of four, Mr N’s observations were not required to be taken again until at least 10.49am. We can see the Trust repeated Mr N’s NEWS2 score approximately 10 minutes later. We think this shows the Trust did recognise Mr N’s deterioration as it increased the frequency of the observations it performed.
30. A NEWS2 score of eight requires the nurse in charge to inform the medical team of the patient’s condition and for an assessment by the critical care team. We can see the Trust actioned this and Mr N was reviewed approximately an hour later.
31. This appears to be in line with NICE guidance on recognising deterioration which says staff should identify signs of deterioration and respond promptly. Our nurse adviser also confirmed Mr N’s deterioration was identified and acted on in a timely manner.
32. We can see Mr N was reviewed by the critical care team, a junior doctor and a consultant. The Trust documented Mr N was drowsy but rousable and it planned to perform an urgent chest X-ray, blood gasses (checks oxygen and carbon dioxide levels in the blood), and an ECG. It also planned to discuss with ITU whether a higher dependency support would be appropriate.
33. We can see at approximately 1.38pm Mr N’s oxygen levels suddenly dropped, and the Trust’s crash team attended. The Trust documented it felt Mr N was dying and end-of-life care was initiated with comfort observations only. Mr N sadly died the same day.
34. We have seen the Trust appears to have acted in line with NEWS2 guidance in its recognition and response to Mr N’s deterioration. We can see the Trust identified Mr N was deteriorating during the morning of 1 May, and he was reviewed by the critical care team and a consultant. We can see following this the Trust took appropriate actions to treat Mr N’s deterioration which was in line with NICE guidance on recognising deterioration.
35. We understand why Mrs E is concerned the Trust missed signs of deterioration in her father. Our adviser explained Mr N suffered a sudden, acute deterioration that could not be reasonably anticipated, and which was managed appropriately. We recognise this was a very distressing time for Mrs E and we hope our decision provides reassurance that the Trust did recognise and act on Mr N’s deterioration in a timely manner.
Communication
36. Mrs E said at no point did the Trust communicate to her how poorly her father was or at what point his condition became critical. Mrs E said within her father’s medical records AKI and sepsis are mentioned multiple times and yet this was never communicated to his family. Mrs E said family members were also unable to be with Mr N when he died due to the Trust not informing them of the severity of his condition.
37. The Trust said Mr N deteriorated rapidly on the day he died, and it apologised that it did not contact Mrs E sooner. The Trust said staff prioritise immediate intervention when a patient deteriorates rapidly, and this may have occupied the staff’s time. The Trust said family members should be contacted at the earliest opportunity.
38. NICE guidance on recognising deterioration says if the patient agrees, carers and relatives should have the opportunity to be involved in decisions about treatment and care, and they should also be given the information and support they need.
39. From the records we can see two days before Mr N died, the Trust documented he had an acute kidney injury (AKI) stage 1. AN AKI is identified from blood tests that were taken the day previously which showed an elevated level of creatinine. An elevated level of creatinine in the blood means that the kidneys are not working as they should. It is important to note Mr N had chronic kidney disease.
40. Mr N also had elevated infection markers and the Trust queried whether he had sepsis. The Trust performed a CT scan and noted there were nodules in the right and left upper lobes of the lungs that were not present on earlier scans. The Trust noted it was likely infective in nature and the cause of the elevated markers and commenced antibiotic treatment. The Trust documented it updated Mr N’s daughter-in-law.
41. The following day we can see the Trust noted Mr N’s AKI was worsening. We can see Mr N’s daughter called at 6.42pm and requested an update as she was concerned for her father. The Trust documented the nurse was currently doing medication rounds and would call her back. We can see Mr N’s daughter called again at 1.22am and requested a call back to her or her sister.
42. As explained above, Mr N began to deteriorate at approximately 7.01am when he had a NEWS2 score of eight. The consultant reviewed Mr N and noted they felt he was in multi-organ failure with sepsis and worsening AKI.
43. We can see the Trust contacted Mr N’s daughter, Mrs E’s sister, and informed her of his clinical condition and deterioration. We can see the Trust recorded it explained to Mr N’s daughter that he had an AKI with ongoing infection which could be sepsis and that his prognosis was guarded.
44. Approximately four hours later we can see the Trust documented Mr N’s wife, son and daughter were at his bedside. The Trust noted Mr N’s family were aware he was very poorly and unlikely to survive the admission.
45. A short time later we can see Mr N deteriorated further and the Trust started end-of-life care, for comfort care only. The Trust documented it had updated family members, and they were aware Mr N was dying, and he was prescribed end-of-life medications. Mr N sadly died that afternoon.
46. We think the Trust appears to have acted in line with NICE guidance on deterioration in the communication it provided on the day Mr N died. We can see the Trust informed Mr N’s family of his deterioration in a timely manner, within approximately one hour of being reviewed by a consultant. Our adviser said this was reasonable as the review and any interventions required would have taken priority.
47. We can see following this the Trust appeared to keep Mr N’s family updated on his prognosis and condition. We can see his family was informed when he was placed on an end-of-life pathway and that he would be receiving comfort care only. We think this is in line with GMC guidance.
48. From the evidence we have seen so far, we do not think the Trust has acted in line with NICE guidance on deterioration during the night of 30 April. We can see Mrs E and her sister requested a call on two occasions during the night and there is no indication the Trust returned these calls. This does not appear to be in line with NICE guidance which says staff should provide information to patient’s families. Our adviser also confirmed the Trust should have returned these calls especially as Mr N’s daughter had expressed concern for her father’s condition.
49. We have considered the impact this had on Mrs E. Mrs E said as a family they have a lot of unanswered questions due to the Trust not communicating with them. Mrs E said her and her family are still trying to come to terms with what happened to Mr N, and this has exacerbated their grief.
50. We can understand why Mrs E has unanswered questions as she was unable to speak to the Trust during the evening the day before her father died. We recognise it would have been shocking when the next day the Trust informed her that her father would not survive the admission. We recognise this would have caused uncertainty for Mrs E and her family regarding what happened.
51. We also recognise the Trust’s communication exacerbated Mrs E and her family’s ability to grieve. We understand this was a very difficult time for Mrs E that was made worse by the lack of communication from the Trust.
52. In the complaint correspondence the Trust said it identified shortfalls in the communication it provided, and this had been shared with the relevant teams. The Trust identified it required improvement in providing timely communication to deteriorating patients and that the nursing and medical teams required reflection and improvement in the communication it provided. The Trust said it had implemented actions for these learning points.
53. Mrs E told us she would like the Trust to apologise, acknowledge what went wrong, implement service improvements and provide a financial remedy.
54. In line with our Service Model Guidance, we can agree a resolution with an organisation if we can achieve a satisfactory result for the complainant with minimal intervention. An investigation would not be necessary if the Trust agreed a resolution at this stage. We would also likely reach the same outcome at the end of an investigation, but this would be a longer process.
55. We understand the suffering Mrs E and her family have experienced is extensive. As set out above, we have not seen any indications anything went wrong with the clinical care provided by the Trust.
56. We have considered the impact Mrs E suffered which we think can be linked to the indication of a failing we have seen. When deciding on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service.
57. We appreciate Mr N’s death has had a profound impact on Mrs E and her family. We discussed with the Trust the indication of a failing we have seen, and the injustice we think this caused.
58. We contacted the Trust and explained where the complaint sat on our severity of injustice scale. We asked the Trust whether it would be willing to pay a financial remedy in line with the guidance. The Trust confirmed it would and it has agreed to pay Mrs E £300 to remedy her complaint. The Trust has also agreed to apologise to Mrs E and acknowledge the indication of a failing we have seen.
59. We think this resolution will put right the impact that appears to have been caused by the indication of a failing we have seen. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services. We think it gives Mrs E an appropriate and proportionate remedy for the indication of a failing we have seen, and the injustice that arose from this.
60. Mrs E had also told us she was seeking service improvements. As set out in paragraph 52, the Trust has already recognised there is work for it to do to try and prevent something similar from happening again. The Trust is implementing actions to address the issues that occurred with communication between staff and family members.
61. We understand Mrs E and her family have experienced understandable grief and distress following Mr N’s sudden death. We hope our decision will offer reassurance to Mrs E that Mr N was provided with care in line with guidance and his deterioration was identified and acted on appropriately.