Monitored bed and observations
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether we can resolve it at an earlier stage in our process. We do this if we can agree with the organisation to take necessary actions to put right the impact of anything that went wrong. We have done this and consider the changes the Trust has agreed to make resolves this part of the complaint.
16. Miss J says, following her mother’s transfer out of the critical care unit, the Trust should have continuously monitored her mother’s condition and the observations it undertook were not enough.
17. RCP ‘National early warning score (NEWS) 2: Standardising to assessment of acute illness severity in the NHS’ explains the NEWS2 guide should be used to decide on the frequency of a patient’s monitoring. A set of vital signs, including heart rate, blood pressure, respiratory rate, oxygen levels, and conscious levels are recorded and scored. Regular monitoring and recording of the NEWS2 score helps nursing staff to see ‘early warnings’ of a patient’s potential clinical deterioration and provides a trigger for escalation of their clinical care.
18. The NEWS2 guide explains that a patient who scores between one and four should be monitored every four to six hours. A patient who scores five or six should be monitored hourly. Patients with a score of seven or more should be continuously monitored.
19. The records indicate that Mrs K’s NEWS2 score was three just prior to her step down to ward-based care on 21 July. Her NEWS2 score remained between three and four up to 11.41pm on 22 July. This meant, to be in line with NEWS2 guidance, the Trust should have monitored her every four to six hours. Unfortunately, this did not always happen within the set timeframe.
20. The clinical records show that Mrs K had low blood pressure at 11.41pm on 22 July and this increased her NEWS2 score to five.
21. The Trust repeated the observations at 0.20am, 1.45am, and 5.48am on 23 July where Mrs K’s NEWS score remained at five. At 6:45am, only Mrs K’s blood pressure was checked and no NEWS2 score was recorded. Our nursing adviser says Trust staff should have repeated Mrs K’s observations hourly during this time and continued to do so given her NEWS2 score.
22. The written nursing evaluations state at 12noon that Mrs K was maintaining her oxygen saturation levels on four litres of oxygen and no concerns were highlighted. However, no further observations were done and her NEWS2 score was again not recorded.
23. Mrs K’s next full NEWS2 score was documented at 2:56pm where her NEWS2 score was recorded as 10 and she was in ‘peri-arrest’. This is the period of time just before a person has a cardiac arrest.
24. Our nursing adviser says Mrs K’s NEWS2 score went from five to 10 during this nine-hour period between observations. Had nursing staff done further observations her clinical deterioration may have been identified earlier and provided a ‘trigger for escalation’ of Mrs K’s clinical care.
25. Although there was no score recorded, nursing staff did continue to monitor Mrs K’s condition and nursing entries were made. Sadly, there is no further documentation until Mrs K’s deterioration was noted at 2.56pm when she was in peri-arrest, so it is difficult to know what happened during this time.
26. At this time, Trust staff escalated their concerns to the Critical Care Outreach Team for review. Mrs K’s treatment escalation plan was updated to request the registrar be notified of further deterioration. Sadly, Mrs K died at 4.20pm.
27. Our physician adviser says there is nothing to indicate the lack of timely monitoring of Mrs K’s observations contributed to her clinical deterioration or impacted on the treatment she received during this time. This is because the Trust were already aware of Mrs K’s poor prognosis and had already made the decision to step-down her care with a focus on comfort rather than invasive treatments.
28. We recognise the upset and distress it caused Miss J when her mother sadly died. Although Miss J understood her mother was ill, we appreciate she had not expected her to die so suddenly. We acknowledge the huge impact her death had on Miss J.
29. Having taken everything into account, we consider the Trust did not always act in line with NEWS2 guidance between 21 and 23 July. This is because it did not always monitor and record Mrs K’s NEWS2 score within the timeframe set in the guidance. This is an indication of a failing.
30. Although we do not consider it had an impact on Mrs K on 21 and 22 July, we consider it may have led to a delay in her deterioration being identified on 23 July. If her deterioration has been identified sooner, our physician adviser said this would not have led to any different treatment being provided as she was already receiving treatment to help her condition. However, we consider this would have allowed for better communication with the family about her worsening condition and could have prepared them better for her approaching death.
31. Our NHS complaints standards say we expect organisations to ‘explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.’
32. We contacted the Trust about the frequency of its monitoring of Mrs K’s condition. The Trust accepts it did not consistently adhere to the timings of observations based on Mrs K’s NEWS2 score. It recognises this could have led to earlier identification of her decline on 23 July and has agreed to apologise to Miss J for this and discuss this complaint further with the relevant teams to share learning.
33. We are pleased the Trust has agreed to apologise for the mistakes it made. While we appreciate this does not change the outcome for Mrs K, we are reassured it has agreed to take action to stop this from happening again going forward. We feel the Trust has acted in line with our NHS complaints standards and has taken appropriate action to resolve this part of the complaint and to take learning to stop this happening again going forward. We will therefore not take any further action on this part of the complaint.
Air mattress
34. Miss J says her mother had bed sores and she should have had appropriate support and an air pressure mattress to help her with this.
35. NICE ‘Pressure redistribution devices’ (2015) says people at high risk of developing pressure ulcers are provided with pressure redistribution devices. These work by reducing or redistributing pressure, friction, or shear forces. Devices include high specification mattresses, pressure redistribution cushions and equipment that offloads heel pressure. Using pressure redistribution devices as soon as possible can prevent pressure ulcers developing and help to treat them if they do arise.
36. The records show Mrs K had a pressure area risk assessment done on transfer to the ward. This showed Mrs K had moisture associated skin damage to her sacrum (triangular bone at the base of the spine) and concluded that she required an air mattress to support her.
37. At 11:40am on 22 July, the records say Mrs K reported to the physiotherapist that she had a ‘sore sacrum’. The physiotherapist further advised nurses that she needed an air mattress to support her.
38. NICE guidance on ‘Pressure ulcers: prevention and management’ says clinicians should encourage high risk adults to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. It also says to document the frequency of the repositioning required.
39. The records show that in line with the above NICE guidance, Mrs K had two hourly comfort rounds and regular positional changes. It is noted that she was in one position for no more than four hours. Regular repositioning aims to reduce or stop pressure on the area at risk.
40. Mrs K was not given an air mattress for the duration of her time on the ward. This is not in line with the NICE Pressure redistribution devices guidance, and this is an indication of a failing. Our nursing adviser says as this mattress is used to provide comfort and prevent further skin breakdown, this likely added to her sacral discomfort.
41. In its complaint response, the Trust accepted it delayed providing Mrs K with an appropriate mattress to support her. The Trust said it has taken learning from this and has notified its staff of the importance of ensuring air mattresses are available to patients who need them as soon as possible.
42. NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’ says nurses should ‘observe, assess, and optimise skin and hygiene status’ and ‘determine the need for support and intervention’. To use contemporary approaches to the assessment of the skin’s condition and use appropriate products to prevent or manage skin breakdown.
43. The Trust’s care round template document states pressure areas should be checked twice a day.
44. While on the ward, Mrs K’s pressure areas were not documented as being checked. This is not in line with the NMC Code and is an indication of a failing. Sadly, as her pressure areas were not checked, and her skin condition was not documented, we cannot say whether any further damage was caused due to the lack of the air mattress.
45. We can say the Trust missed an opportunity to manage her skin condition to ensure there was no further breakdown and to manage the pain associated with this. We consider the inappropriate mattress meant Mrs K likely suffered further sacral discomfort.
46. We discussed this further with the Trust. The Trust has agreed to apologise again that it did not provide an appropriate mattress for Mrs K and has confirmed the learning that has already taken place in respect of this.
47. While the Trust did ensure Mrs K was regularly repositioned to avoid pressure on the affected area, it says it will acknowledge and apologise that her pressure areas were not checked.
48. The Trust said it has requested the relevant staff attend pressure ulcer management and prevention training to improve their knowledge in this area. The Trust has also provided its staff with pocket cards to help them with identifying the correct categorisation for pressure ulcer. Alongside this, the Trust says the pressure ulcer mattress selection guidance poster is now displayed on the ward to ensure appropriate and timely decision making around the correct equipment required.
49. We consider the Trust has acted in line with our NHS complaints standards and has taken appropriate action to resolve this part of the complaint and to take learning to stop this happening again going forward. We will therefore not take any further action on this part of the complaint.
Blood glucose (sugar)
50. During our consideration of a complaint, we must 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 have done this and the evidence we have indicates the Trust appropriately monitored Mrs K’s blood glucose levels.
51. Miss J says a contributing factor in her mother’s death, according to the coroner’s report, was diabetes mellitus. This condition affects how the body uses blood glucose which is a vital source of energy for cells. Miss J says the Trust did not check and monitor her mother’s blood glucose levels.
52. She says she is still left wondering whether her mother’s blood glucose levels were too high or too low and this is what made her deteriorate so quickly. She says she wants to know whether it would have changed her outcome had this been checked and acted on.
53. The NHS webpages for Empagliflozin and Metformin say these medications are often used to treat type 2 diabetes.
54. The NHS webpage for Insulin for type 2 diabetes says insulin medication reduces the chances of getting symptoms of high blood glucose (hyperglycaemia). Sometimes this may be needed if you are ill and need to keep your blood glucose levels under control. This must be balanced against the risk of harm due to low blood glucose levels (hypoglycaemia) and serious long-term problems such as damage to your heart, kidneys, eyes, and nerves.
55. On admission, Mrs K was taking Empagliflozin and Metformin medication tablets for her type 2 diabetes condition. Our physician adviser says these tablets are used to lower blood glucose levels. However, in the context of acute illness, it is sometimes necessary to stop both empagliflozin and metformin as they may both cause acidosis (an excess of acid in the body) when someone is very ill. Therefore, the Trust appropriately, and in line with the NHS webpage, changed Mrs K’s treatment from tablets to insulin injections.
56. Capillary blood glucose (CBG) refers to the measurement of glucose levels in the blood. JBDS-IP ‘Inpatient care of the frail older adult with Diabetes’ guidance says if the CBG is more than 12 mmol/L, the frequency of monitoring should be increased to four times daily.
57. The records show the Trust monitored Mrs K’s blood glucose levels during her admission. Between 21 to 23 July, following her transfer to ward-based care, as her CBG was more than 12 mmol/L, the records show she was monitored every few hours in line with JBDS-IP guidance.
58. JBDS-IP guidance also says an acceptable inpatient glucose range is between 6-12mmol/L. However, targets should be individualised. This is because managing diabetes in an older person should be aligned with their individual ability to perform daily activities, presence of frailty, other health conditions, quality of life, and life expectancy. The target for a frail older adult should be to achieve the best glycaemic control which does not compromise the quality of life with additional treatment burdens and does not increase the risk of hypoglycaemia (low blood sugars).
59. Although the JBDS-IP guidance says an acceptable range would be between 6-12mmol/L, our physician adviser says an individualised target range of 6-15 mmol/L would be appropriate for Mrs K in the context of her illness. Mrs K did experience some glucose levels above the target. However, this was not sustained and quickly came back within the target range.
60. Our physician adviser said given Mrs K’s poor prognosis, it was important to achieve the best glycaemic control and not introduce ‘additional treatment burdens’. Therefore, further action on those readings was not needed.
61. Having taken everything into account, we consider the Trust appropriately changed Mrs K’s medication from tablets to insulin injections. We also consider it appropriately checked and closely monitored Mrs K’s blood glucose levels in line with the JBDS-IP guidance to ensure she received the best individualised care for her condition. For this reason, we have not seen any indications of failings and will not be taking any further action on this part of the complaint.
62. We recognise how distressing it was for Miss J to see diabetes mellitus recorded under section two of her mother’s death certificate. Section two refers to ‘other significant conditions contributing to the death but not related to the disease or condition causing it’. Our physician adviser said as Mrs K lived with this condition, it is likely it did have an impact on her health over time. However, it did not lead to, or cause, her death.
63. We hope it provides Miss J some reassurance to know that we have seen evidence the Trust appropriately monitored and managed her mother’s diabetes condition during her admission.
Suction to aid breathing 64. In the afternoon of 23 July, Miss J says her mother’s breathing was deep, rattly, and sticky. She says Trust staff should have given her ‘suctioning’ to help with her breathing.
65. Suctioning is a procedure used to remove substances from the trachea (windpipe), pharynx (part of the throat), nose, or mouth.
66. The CRJ ‘Updating the evidence base for suctioning adult patients: A systematic review’ report says physiotherapists, respiratory therapists, nurses, and physicians use suctioning to promote secretion (mucus) clearance and/or to maintain a patient’s airway. This is to lower the risk of infection and to better a person’s lung function. This technique is used in patients who struggle to remove such substances. Effective suctioning is an essential aspect of airway management but there are many associated risks and complications. As suctioning is an invasive and potentially hazardous procedure, it should not be routinely done. The recommendations prior to suctioning include patient assessment, patient preparation, and hyperoxygenation (excessive oxygen in the lungs or other body tissues).
67. Our nursing adviser explains that in line with the above report, appropriate assessments would need to be carried out before suctioning would be done. The Trust’s physiotherapists assessed Mrs K and documented on 22 July that she had a ‘strong cough’. Our nursing adviser says this shows she was able to clear her own secretions. When a person can do this naturally then suctioning would not be done.
68. The NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’ says a nurse must ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’ and ‘make a timely referral to another practitioner when any action, care or treatment is required’.
69. Our nursing adviser says if a nurse finds that a patient is struggling with the removal of secretions, they would need to escalate this to ensure a further assessment is carried out. This assessment would give due weight to the complications and risks associated with suctioning and would establish suctioning would be safe before recommending.
70. Although Mrs K’s NEWS2 score was not recorded within the timescales set out in NEWS2 guidance, in line with the NMC Code nursing staff continued to monitor her condition. The 11.20am and 12noon entries indicate Mrs K was maintaining her oxygen saturation levels on four litres of oxygen and there is nothing to suggest she needed further intervention with clearing her airways or with her breathing.
71. Therefore, there is nothing to suggest that Mrs K needed a further assessment to determine whether suctioning was required at this stage.
72. At 2:56pm when Mrs K’s NEWS score rose to 10, nursing staff appropriately escalated their concerns to the medical team to review her. This was in line with the NMC guidance.
73. The medical team reviewed Mrs K straight away. The records indicate she was ‘short of breath’ and having ‘difficulty breathing’ although she was not in any ‘obvious distress or pain’. Anticipatory medications were prescribed. These are a small supply of injectable medicines prescribed in advance for patients, particularly those nearing the end of life, to manage potential distressing symptoms.
74. The doctor appropriately referred Mrs K to physiotherapy for further review. Sadly, this did not take place before she died.
75. We recognise how difficult and distressing it was for Miss J to see her mother so gravely ill. We understand that she considered suctioning would have helped her mother’s breathing because it had become deep, rattly, and sticky. Although a further physiotherapy review was requested, given Mrs K’s condition and poor prognosis, in line with the CRJ report it is unlikely that an invasive procedure like suctioning would have been appropriate or recommended.
76. We hope it provides Miss J with some reassurance to know that the lack of suctioning did not lead to, or contribute, to her mother’s death.
Antibiotics
77. Miss J says the Trust did not administer antibiotics to her mother consistently every 12 hours. She says this led to her rapid deterioration and caused her to die prematurely.
78. BNF ‘Co-trimoxazole’ guidance says to use this medication to treat susceptible infections twice daily or every 12 hours.
79. On 19 July, Mrs K’s blood test results showed signs of infection, so the Trust administered her with co-trimoxazole (antibiotics). This continued when her care was transferred to the ward.
80. The medication administration chart shows this was to be given ‘12 hourly BD’. Our nursing adviser says this means it should be given every 12 hours or twice a day.
81. Our nursing adviser says the co-trimoxazole medication was given by intravenous (IV) infusion over a 90-minute period and the records show it was given twice a day. Our nursing adviser said a slight delay period of one-hour would not have impacted Mrs K’s clinical condition.
82. We appreciate the upset it caused Miss J to see her mother not being given prescribed medication at the time she deemed it should have been. We acknowledge this made her feel that her mother was not being given the best care or the treatment she desperately needed to aid her recovery.
83. Having taken everything into account, we consider the Trust acted in line with BNF guidance in its administering of co-trimoxazole medication to Mrs K. For this reason, we have not seen any indications of failings and will not be taking any further action on this part of the complaint.
84. We recognise how important this complaint is to Miss J so we hope she is pleased that the Trust has taken learning from it. We would like to thank her for her time and effort in bringing this complaint to us.