Diabetes and Ms A’s hypoglycaemic event
21. Miss T said she provided the Trust with a list of approved foods her mother could eat due to her diabetes being controlled through her diet. Miss T said the food the Trust supplied was not sufficient for managing Ms A’s diabetes through her diet.
22. The Trust said an extensive list of Ms A’s dietary needs was taken and added to PICS (the Trust’s internal recording system) on her admittance. The Trust said Ms A’s dietary intake was poor and she was seen by a dietitian who prescribed her nutritional supplements. The Trust explained it was difficult at times to maintain Ms A’s oral intake due to her deteriorating clinical condition and nausea symptoms.
23. NICE guidance on diabetes says clinicians should adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of the patient. As set out above, Ms A had diabetes which was controlled by her diet.
24. From the records we can see Ms A was admitted to a ward in mid-July. We can see the following day her family provided the ward with a list of the food Ms A could and couldn’t eat to help manage her diabetes.
25. We can see a dietitian reviewed Ms A three days later and noted she had suboptimal oral intake. The dietitian documented Ms A had ongoing weight loss and she declined most of the oral nutritional supplements that were offered. We can see the dietitian requested food and fluid charts be completed for Ms A.
26. We have not seen any reference to Ms A’s diabetes or how her diet should be tailored to accommodate this within this review.
27. We can see approximately ten days after being admitted, Ms A’s daughter requested chicken soup be provided to her mother daily. We can see staff requested this from the catering team.
28. The Trust has been unable to provide Ms A’s food and fluid diaries for the requested timeframe. The Trust has told us it was likely these charts were completed at the time but may have been lost due to human error during the filing process. This makes it difficult for us to reach a view on whether the Trust was appropriately managing Ms A’s diabetes and dietary needs.
29. We can see the dietitian requested food charts be kept within three days of Ms A’s admittance. We have not seen any further reference within the records that would indicate staff were completing a food diary or monitoring Ms A’s oral intake.
30. We also did not see any reference that the Trust had noted Ms A had diabetes, or that her diabetes was diet controlled. Based on this we think it was likely the Trust was not meeting Ms A’s dietary needs and therefore not appropriately managing her diabetes.
31. We have found the Trust has not acted in line with NICE guidance on diabetes. We can see the Trust noted Ms A’s dietary needs within the medical records and listed the food that was she able to consume.
32. We have not seen any evidence the Trust implemented these dietary requirements or provided a dietary care plan. This is not in line with NICE guidance on diabetes which says clinicians should adopt an individualised approach that meets the needs of the patient.
33. We will next look at whether the Trust should have monitored Ms A’s blood sugar during her admittance.
34. Miss T said the Trust was made aware of her mother’s diabetes and despite this, it was not monitoring her blood sugar levels. The Trust said it was unaware of Ms A’s diabetes, and it had not been documented on its PICS system. The Trust said if it had been aware, then it would have monitored Mrs A’s blood sugar levels daily.
35. We understand the Trust has told us it was unaware of Ms A’s diabetes and therefore was not monitoring her blood sugar. We have seen evidence within the medical records, prior to the events complained about, that the Trust was aware of Ms A’s diabetes and that it was controlled by her diet. We therefore think the Trust should have been aware of this.
36. NMC the Code says nurses must deliver the fundamentals of care effectively. Our nursing adviser explained there would be a nursing expectation to record Ms A’s blood glucose results before and after eating due to her diabetes. They explained this is to identify any potential hypoglycaemic (low blood sugar) or hyperglycaemic (elevated blood sugar) readings.
37. We can see on 24 July the Trust noted Ms A was hypoglycaemic and her blood glucose level was 1.6 mmol/L. The normal range for a person with type two diabetes should be between 4 to 7 mmol/L. We can see the Trust noted Ms A’s blood sugars were low and it commenced IV glucose and provided an oral glucose gel.
38. We can see approximately an hour later the Trust noted Ms A’s blood glucose level was still low at 2.7 mmol/L. We can see the Trust repeated the blood glucose check approximately two hours later and noted Ms A’s levels were in the normal range at 5.1 mmol/L.
39. From the evidence we have seen, we have found the Trust has not acted in line with NMC the Code. The Trust did not check Ms A’s blood sugar levels until 12 days into her admittance when she was found to be unconscious, and hypoglycaemic.
40. As Ms A had type 2 diabetes that was diet controlled, in line with NMC the Code, the Trust should have monitored this whilst Ms A was an inpatient. Our nursing adviser confirmed this should have happened.
41. We have found the Trust not monitoring Ms A’s blood sugar was not in line with NMC the Code which says nurses should deliver the fundamentals of care effectively. We acknowledge this will be distressing for Miss T, particularly given the steps she took to support her mother with this. We will consider the impact of this further below.
42. Miss T said her sister and niece attended the Trust on 24 July and found her mother to be unresponsive. Miss T said her sister pressed the emergency button as her mother’s eyes had rolled into the back of her head and staff were unaware of her condition.
43. Miss T said it should not have taken her sister and niece to find her mother in this condition and the Trust should have been monitoring her. We recognise how distressing this would have been for Miss T, her sister and her niece.
44. 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.
45. NEWS2 guidance says if a patient scores between one and four, this requires observations to take place between four to six hourly.
46. From the records we can see the Trust performed Ms A’s observations at 4.40am and documented she had a NEWS2 score of two. A NEWS2 score of two means there is a low risk of clinical deterioration, so observations only need to be taken four to six hours later.
47. We can see Ms A scored two due to having low blood pressure and the Trust noted this was normal for her. We can see Ms A was admitted with low blood pressure and was receiving treatment for this. In line with NEWS2 guidance Ms A’s observations would not need to be repeated until 10.40am.
48. We can see at 8am the Trust documented it offered Ms A a nutritional supplement which she declined.
49. We can see at approximately 10.24am Ms A was found to be unresponsive by her daughter and the emergency buzzer was pressed. This was within the six hour timeframe as detailed in the NEWS2 guidance as Ms A’s observations were not due for approximately 15 more minutes.
50. We have found the Trust acted in line with NEWS2 guidance. We can see Ms A had a NEWS2 score of two which meant she was at low risk of deteriorating, and her observations did not need to be repeated for up to six hours. Ms A was found unresponsive approximately 20 minutes before this timeframe was due to end.
51. As explained in paragraph 41 we have found a failing in the Trust not monitoring Ms A’s blood sugar levels. Our nursing adviser said the Trust should have been monitoring Ms A’s blood glucose before and after meals. This would suggest the Trust should have monitored Ms A’s blood sugar levels between 4.40am and 10.40am.
52. We have found the Trust has not acted in line with NMC the Code. We know the Trust offered Ms A a nutritional supplement at 8am, which is likely around the time breakfast was being offered.
53. If the Trust was monitoring Ms A’s blood sugar as it should have, it may have identified her risk of becoming hypoglycaemic and taken steps to reduce this risk. Based on this we do not think the Trust delivered the fundamentals of care effectively as it was not monitoring Ms A as it should.
54. In summary, we have found the Trust failed to manage Ms A’s diabetes in line with guidance, as it did not provide appropriate food. We have also found the Trust did not monitor Ms A’s blood sugar levels as often as it should have.
55. We have considered the impact of these failings.
56. Miss T said it was incredibly distressing to learn her sister and niece had found her mother unresponsive, hypoglycaemic and the Trust was unaware of this drastic deterioration. Miss T has also told us if the Trust was manging her mother’s diabetes as it was supposed to, she believes the hypoglycaemia would not have happened.
57. We recognise it would have been very distressing and traumatic for Miss T to learn her mother was unresponsive for an unknown period of time. We have been unable to determine how long Ms A was unresponsive for prior to her daughter arriving. We understand this will cause uncertainty and distress to Miss T.
58. As explained in paragraph 36 the Trust should have been monitoring Ms A’s blood sugar levels after each meal. We can see Ms A declined a nutritional shake at approximately 8am and it would seem likely she was offered breakfast around this time.
59. We do not know whether Ms A had eaten on the morning of the hypoglycaemia or what her blood glucose measurement may have been if the test was completed. The Trust said Ms A’s dietary intake was poor and she regularly declined the oral nutritional supplements. The Trust said due to Ms A’s poor clinical condition it was difficult to maintain her oral intake.
60. We are not able to say the Trust not monitoring Ms A’s blood sugar levels caused the hypoglycaemic event. This is because even if the Trust had monitored her blood sugar levels, the outcome may have been the same. It is not possible to say now whether if the Trust had checked Ms A’s blood sugar level, what the result would have been.
61. We understand this will cause uncertainty and distress to Miss T regarding whether there was an opportunity for an earlier intervention.
62. Miss T said her mother developed hypoglycaemia due to the Trust not providing adequate food for her needs. Miss T said if the Trust had managed and monitored her mother’s diabetes appropriately, she would still be alive.
63. We acknowledge Miss T believes the Trust’s failings here led to Ms A becoming hypoglycaemic. We recognise Miss T has told us she believes this hypoglycaemic episode led to her mother’s premature death.
64. We have found the Trust should have provided adequate food for Ms A’s diabetes and monitored her blood sugar levels. We have not been able to link this to a clinical impact for Ms A. We have explained our thinking below.
65. We can see Ms A was admitted to the Trust with terminal ovarian cancer, a new onset of confusion, black tarry stool and suspected upper GI bleed. Throughout her admittance we have seen references within the medical records that Ms A’s oral intake was poor, that she declined food, and she was suffering from nausea.
66. We can see the Trust referred Ms A to the palliative care team on the third day of her admittance. On the fourth day the Trust noted Ms A’s prognosis was very poor, and she was for palliative care.
67. On the fifth day of her admittance, we can see the oncologist reviewed Ms A remotely. The oncologist noted Ms A had been deemed too unwell for chemotherapy at her last review three weeks previously. They noted Ms A was purely for palliative treatment and there was nothing that could be offered from an oncology perspective.
68. We can see a consultant reviewed Ms A the same day and noted she had lost muscle mass due to the underlying cancer and poor oral intake.
69. Three days later we can see the palliative care team requested anticipatory medication be prescribed for Ms A. Anticipatory medication is medication to relieve distressing symptoms in patients who are nearing the end of their life.
70. Ms A was found to be unresponsive and hypoglycaemic approximately four days later. We understand Ms A becoming hypoglycaemic and unresponsive would have been shocking, worrying and distressing for Miss T and her family.
71. We are not able to say Ms A becoming hypoglycaemic was due to a failure of the Trust. This is because we do not have enough evidence regarding why Ms A’s oral intake was poor.
72. We can see Ms A was very poorly throughout her admission which would likely have impacted her ability to eat. We have seen the dietitian also noted Ms A had lost a substantial amount of weight from three weeks previously. This would indicate Ms A’s reduced oral intake and weight loss had begun prior to her admittance.
73. Due to how unwell Ms A was during her admittance, we are not able to say the food the Trust provided impacted her clinical condition or caused her to become hypoglycaemic.
74. Our adviser explained there can be a sudden decline or deterioration in patients with a serious illness, such as cancer, that is very difficult to predict. Our adviser explained there is not always an event that triggers this decline when a person is nearing the end of their life.
75. We understand Miss T has told us she thinks her mother would still be alive if the hypoglycaemic event had not happened. We are not able to link the Trust’s failing to manage Ms A’s diabetes to her sad death. We acknowledge Miss T may be distressed by this.
76. This is because we can see during the first week of her admittance the Trust documented she had a poor prognosis, was for palliative care only and had been prescribed anticipatory medications. This would suggest Ms A was very poorly and was identified as nearing the end of her life towards the beginning of her admittance to the Trust and was not caused by the hypoglycaemia.
77. We can understand why Miss T felt the Trust not managing her diabetes contributed to her death. We recognise this has caused worry and distress to Miss T. We hope our decision provides reassurance to Miss T that the hypoglycaemia did not cause Ms A’s death and that, sadly, her outcome would likely have been the same irrespective of the Trust’s diabetes management.
78. We have made recommendations to recognise the emotional impact the Trust’s failing had on Miss T. Details of these recommendations can be found towards the end of this report.
Communication
79. Miss T said the Trust did not communicate with her regarding Ms A’s condition. She said the Trust did not provide updates despite Ms A’s condition deteriorating and it did not make her aware of the seriousness of her condition. The Trust acknowledged Miss T concerns and said it would make staff aware of the importance of providing updates to family members.
80. GMC good medical practice says doctors must make sure that the information they give is clear, accurate and up to date, and based on the best available evidence. GMC guidance says doctors must be considerate to those close to the patient and be responsive in providing information and support.
81. From the records we can see the day Ms A was admitted to the Trust she was seen by the consultant with her daughter, Miss T’s sister, present. We can see the consultant provided an explanation of what was happening to Ms A and Miss T’s sister, and it noted Miss T was also happy to be called for an update.
82. We can see the following day the consultant noted they discussed Ms A’s condition with her and Miss T’s sister. We can see the consultant explained they suspected Ms A had internal gastric bleeding and that she was very poorly. We can see the consultant advised that treatments may not work, and they discussed the plan of care and escalation plan. We can see that they agreed Ms A should not be for resuscitation or ITU care (intensive treatment unit) if her condition were to worsen.
83. On the third day of Ms A’s admittance, we can see the Trust explained to Ms A and her family of her recent results and the current plan of care. We can see the Trust referred Ms A to palliative care and documented this had been explained to the family. We can see the following day it was documented Ms A’s prognosis was very poor and her condition was palliative.
84. On the sixth day of Ms A’s admittance, we can see the palliative team spoke with Ms A’s daughter and niece. We can see the palliative team discussed Ms A’s deterioration and her blood results. The Trust noted Ms A’s daughter looked after her at home and she was keen to be discharged.
85. We have seen numerous references that family members were present on the ward during doctor reviews. We have also seen information was provided to them on request over the phone by nurses during Ms A’s admittance.
86. On 24 July Ms A was found to be unresponsive by her daughter. We can see the consultant noted Ms A’s two daughters were present. We can see Miss T requested to know why her mother had deteriorated and whether her condition was reversible. We can see the consultant noted they provided a full account of events to Miss T and discussed what they would like to happen if Ms A deteriorated further.
87. We can see approximately 90 minutes later the nurse documented Ms A had a NEWS2 score of 8 and contacted the consultant. We can see it was noted Ms A appeared to be end of-life and the consultant contacted her next of kin to advise this.
88. Later that day we can see Miss T asked the doctor if her mother was end-of-life as they would like to take her home if she was. The doctor informed Miss T they were treating her mother’s symptoms but that nothing seemed to be reversible. We can see the doctor informed Miss T that continuing tests and providing IV fluids was not going to be beneficial for Ms A and her care was changed to comfort observations only.
89. Following this we can see the palliative and support care team spoke with Ms A’s daughter and noted they agreed the discussion would be relayed to Miss T. We can see the Trust was attempting to fast-track Ms A’s discharge home due to her being end-of-life and this was discussed with family members. Ms A sadly died during the early hours of the next morning.
90. From the evidence we have seen, we have found the Trust has acted in line with GMC guidance in the frequency of the updates it provided to Ms A’s family. We can see there are regular entries referring to Ms A’s family members being provided an update on her condition and the plan of care.
91. We have also seen Ms A’s family members were regularly present on the ward during ward rounds and doctor’s assessments. Our adviser explained this would have provided an opportunity to the family to ask questions of the healthcare team and be updated on her current condition. We have found the Trust has acted in line with GMC guidance which says doctors must be considerate in providing information.
92. We will next look at whether the Trust made Miss T aware of the seriousness of Ms A’s condition.
93. As explained in paragraphs 81 to 89, we can see discussions took place with family members regarding Ms A’s condition. We can see the day after Ms A’s admittance she was referred to palliative care and Ms A and her daughter were informed of this and that she was very poorly.
94. The next day we can see the Trust performed an abdominal CT scan which showed disease progression. We can see the Trust noted it discussed these results with Ms A and her family, and it was explained she would be referred for palliative care, which we can see was actioned.
95. A few days later we can see the palliative team discussed Ms A’s blood results and the markers of deterioration that could be seen. Three days later we can see the Trust also prescribed anticipatory medication which is medication to relieve distressing symptoms in patients reaching the end of their life.
96. The day prior to Ms A’s death we can see the Trust explained to family that Ms A was for end-of-life care.
97. From the records it would appear Ms A’s daughter was informed the day after Ms A’s admittance that she was very poorly. The conversation note was detailed and would indicate this discussion took place. In the days that followed we can see Ms A’s condition was noted to be palliative and she was referred to palliative care with a poor prognosis and it was documented family were aware of this.
98. The difficulty we have is determining whether the seriousness of Ms A’s condition had been clearly conveyed by the consultant and understood by Ms A, her daughter (Miss T’s sister) and Miss T. Our adviser explained the communication recorded by the Trust, and provided to family, painted a very poor picture of Ms A’s clinical condition.
99. From the evidence we have seen, we have found the Trust has acted in line with GMC guidance. We can see the Trust has recorded conversations between itself and family members where Ms A’s prognosis was explained to family. We can see the palliative care team also noted it discussed how Ms A’s blood results demonstrated disease progression and deterioration in her condition.
100. We acknowledge Miss T feels the Trust did not make her aware of the seriousness of her mother’s condition. Given this, we understand how distressing Ms A’s deterioration and death would have been for Miss T.
101. We have found the Trust’s communication was in line with GMC guidance which says doctors should provide up-to-date information based on the best available evidence. We acknowledge Miss T will be disappointed by this.
Death Certificate
102. Miss T said the death certificate stated her mother’s cause of death was metastatic fallopian tube cancer. Miss T complains this is incorrect as her mother had ovarian cancer (not fallopian tube cancer).
103. The Trust said Mrs A was diagnosed with ovarian cancer in October 2017. The Trust said in February 2019 a further histology was taken due to Ms A’s presenting concerns, and she was diagnosed with fallopian tube carcinoma. This is cancer that originated in the fallopian tubes. The Trust explained the ovaries and fallopian tubes are connected structures and histologically will be closely related.
104. The Government death certificate guidance says doctors are expected to state the cause of death to the best of their knowledge and belief. It goes on to say that doctors are not expected to be infallible (incapable of making mistakes).
105. From the records we can see the Trust recorded Ms A was diagnosed with a malignant ovarian tumour in June 2017. We can see the Trust performed a biopsy, surgery and provided chemotherapy.
106. In February 2019 we can see Ms A reported ascites which is an abnormal build-up of fluid in the abdominal cavity. We can see in July 2019 the Trust documented Ms A’s cancer had relapsed and she was diagnosed with carcinoma of the fallopian tubes.
107. We can see the Trust recorded Ms A’s cause of death as: I (a) metastatic fallopian tube cancer on the death certificate.
108. From the evidence we have seen, we have found the Trust has acted in line with the Government death certificate guidance. We can see Ms A’s diagnosis was noted as being carcinoma of the fallopian tubes in July 2019. We have also seen Ms A attended an oncology review in June 2023, a month before the events of the complaint, and it was noted her diagnosis was fallopian tube carcinoma.
109. We have seen Ms A’s cancer being referred to as both ovarian and fallopian tube throughout the medical records. Cancer Research UK says doctors think that the most common type of ovarian cancer usually starts in the end of the fallopian tube, rather than the ovary, and may call it fallopian tube or ovarian cancer. The Macmillan webpage also confirms that both terms are used interchangeably.
110. We can see the Trust was using these terms interchangeably and we understand this was confusing and distressing for Miss T. We have found the Trust completing Ms A’s cause of death as fallopian tube cancer, and not ovarian cancer, was in line with the Government death certificate guidance. This says clinicians should complete the cause of death to the best of their knowledge.
111. Miss T also said her mother’s death was caused by hypoglycaemia, due to the Trust not monitoring her blood sugar levels and was not caused by her cancer diagnosis. The Trust said it felt Mrs A’s hypoglycaemia reflected that she was end-of-life and was a symptom that she was dying.
112. Please see paragraphs 64 to 71 where we have been unable to link the hypoglycaemic event to the clinical impact of Ms A’s death.
113. The Government death certificate guidance also says the underlying cause of death may be a longstanding, chronic disease that predisposed the patient to later fatal complications. Based on this we think the Trust acted in line with the Government death certificate guidance when it recorded the cause of death as being metastatic fallopian tube cancer.
114. This is because we can see Ms A was recorded as having a poor prognosis and was for palliative care days into her admittance and nine days before the hypoglycaemic event. Our adviser also explained hypoglycaemia could not be recorded as a cause of death as it is not itself a disease but a condition or a clinical finding.
115. We can see on 20 July the oncologist noted Ms A had a performance status (PS) of four which had increased from three at the time of her admittance. They also noted Ms A was no longer receiving active treatment for the cancer due to her poor PS.
116. Cancer Research UK website explains PS is a scale used to grade how well a person is, their cancer related symptoms and what activities they can do. A PS four is the highest PS and means a person requires full care and is in bed or a chair all the time.
117. We also seen the Trust prescribed anticipatory medication and noted Ms A was unwell due to the underlying cancer approximately one week prior to the hypoglycaemic event. Based on this we have found the Trust recording Ms A’s cause of death as I (a) metastatic fallopian tube cancer was in line with the Government death certificate guidance. This says doctors should complete the death certificate to the best of their knowledge which we have found the Trust did.
118. We can understand why Miss T has been concerned the death certificate was incorrectly completed. We acknowledge this has been an extremely difficult time for Miss T and her family. Our decision is in no way intended to detract from that.