Nutrition, fluids and weight
31. Mrs P has raised concerns the nutrition and fluids her husband received was not adequate and he was left for long periods of time without any food or fluid. She adds Mr P’s food and fluids were provided based on his weight when he was admitted to hospital, but as he lost so much weight during his time as an inpatient this was never re-assessed, and he was therefore receiving the wrong amount of food and fluid. Mrs P also has concerns her husband was not provided with IV fluids.
32. We understand Mrs P’s concerns especially with her husband’s condition at the time. Worrying about Mr P’s nutrition and fluids must have been distressing for Mrs P.
33. The Trust says, ‘Staff did not follow local/national guidance for screening patients in a hospital setting. Had they followed the guidance set out, the patients nutritional needs would have been re-evaluated in a timely manner, thus reducing the risk of further malnutrition and delay in treatment. Had the patient been weighed, preventive steps could have been taken in line with trust policy, to try and prevent further weight loss.’
34. Mr P’s medical records show the Trust estimated his weight to be 79.5kg on 25 October 2022 and began a feeding regimen based on this. We can see Mr P was receiving around 1741kcal per day and around 87g of protein a day.
35. The PENG guidance advises for ICU patients they should receive between 20 to 25kcal per kg per day. This can go up to 30kcal per kg per day for severely unwell patients. The guidance also says a patient should receive between 1.2 and 1.5g of protein per kg per day.
36. Therefore, based on Mr P’s estimated weight of 79.5kg, he needed between approximately 1590 and 1990kcal per day and between 95 and 120g of protein per day.
37. Mr P was therefore receiving the appropriate number of calories per day based on his estimated weight of 79.5kg. However, he was receiving a slightly lower amount of protein per day.
38. Our dietitian adviser says whilst the protein intake was slightly lower than expected it is normal practice for dietitians to make sure a patient is receiving the correct number of calories first and then work on the protein at a later date.
39. We therefore consider Mr P was receiving the appropriate amount of food for his estimated weight of 79.5kg.
40. We considered what Mrs P told us about the Trust not weighing Mr P and working on an estimated weight. The Trust used Mr P’s estimated weight of 79.5kg from 25 October until 17 December 2022 when it was able to weigh Mr P. Mr P’s medical records prior to this date show the Trust were unable to weigh him due to him being in ICU and his condition when he was first transferred to ward 6AB. In December it is documented he then weighed 60.7kg so had lost weight during his time in hospital and therefore his feeding regimen was updated in line with his new recorded weight.
41. Our dietitian adviser says there is no specific guidance which says a patient’s weight needs to be established within a certain timeframe. They added it is an understanding that patients would be weighed as soon as is possible.
42. The Trust says 17 December 2022 was the first time it was able to correctly weigh Mr P. We have seen no evidence to suggest differently, or that this could have been done at an earlier point. Therefore, we consider there has been no failing in this element of the complaint.
43. We have considered Mrs P’s concerns about the fluids Mr P was receiving.
44. The NICE IV fluid guidance says fluid given is determined by body weight and is 25-30ml of fluid per kg of body weight over 24 hours. However, fluid intake will need adjusting for patients with complex needs such as renal, liver or cardiac impairment, fluid retention, malnourishment and severe sepsis.
45. The NICE IV fluid guidance says it is difficult to measure both input and output of fluids accurately. This is because patients do not only take in fluid via IV, but fluid can also be taken in via fluids by mouth and as part of medications. The guidance also says output of fluid is not just measured by urine as fluid is also lost through faeces, breathing and sweating. Therefore, it is difficult to fully understand how much fluid a patient is taking in.
46. Mr P’s medical records show two ECGs were completed which showed he had a weakened heart and heart failure on the left side of his heart. The NICE IV fluid guidance says patients with heart failure are at risk of a pulmonary oedema and therefore Trust’s are cautious about overloading patients with heart failure so that they do not suffer from a pulmonary oedema.
47. We can see from Mr P’s blood biochemistry results his urea levels slightly increase in his first week of admittance. A normal level of urea is up to 7.8 and Mr P’s rose to 13 at one point during his first week. Our physician adviser says urea levels in the blood rise when a patient is dehydrated.
48. Our physician adviser also says whilst urea is an indicator of dehydration, Mr P’s levels only showed signs of slight dehydration and was not a cause for concern. We can see from his medical records after the first week of admission Mr P’s urea goes back to within a normal range and remains within this range for the rest of his admission.
49. Therefore, we consider he was receiving the appropriate amount of fluid during his admission.
50. It is also important to note, the Trust prescribed Mr P furosemide on 26 October. This is a drug which is used to remove fluid. We understand this is because Mr P had developed fluid on his heart and the Trust needed to get rid of this fluid. Our physician adviser says this could suggest why Mr P showed signs of dehydration during his first week, as in line with the NICE IV fluid guidance the Trust erred on the side of caution to ensure Mr P did not receive too much fluid.
51. Despite Mr P showing some signs of slight dehydration in his first week in hospital we consider this was due to the Trust ensuring his risk of suffering a pulmonary oedema was lowered and is in line with the NICE IV fluid guidance. We also consider during Mr P’s stay his fluid intake and output was appropriately managed by dietitians, doctors and nurses and we have seen no indication of a failing or that his fluids were not appropriately managed.
52. We understand how distressing it must have been for Mrs P to see her husband poorly and losing weight in hospital. This must not have been easy for her, and we understand why she had concerns. We hope our findings provide some answers and reassurance about the care her husband received during his time as an inpatient.
Feeding tubes
53. Mrs P has raised concerns her husband’s feeding tube was not inserted correctly and became blocked at times.
54. We understand how worried Mrs P was about her husband’s weight loss and believing there was an issue with his feeding tube would have contributed to this.
55. The Trust says feeding tubes are very difficult to insert but it has not identified any issues with the insertion or working of Mr P’s tubes.
56. Mr P’s medical records do not show his feeding tube was not inserted correctly or became blocked. However, we can see there were a number of occasions where Mr P removed his feeding tube which would mean it could not work properly. There is also a note in his record that he struggled with tolerating his feeds due to high aspirates (when food or water gets stuck in the airway).
57. When this was identified the Trust used a bridle (a fixation device made of silicone tubing and a plastic clip that holds the feeding tube in place) to prevent Mr P from removing his feeding tube. When Mr P removed his tube the Trust ensured a new tube was fitted. Mr P’s medical records also show the high aspirates was escalated to the medical team and dietitian which resulted in changes to his feeding regimen.
58. The NMC guidance says, ‘8.1 respect the skills, expertise, and contributions of your colleagues, referring matters to them when appropriate; 8.5 work with colleagues to preserve the safety of those receiving care; 8.6 share information to identify and reduce risk’.
59. We consider, the Trust acted in line with this guidance to ensure Mr P’s tube was inserted and working correctly. Therefore, we do not consider there has been any failings in this part of Mrs P’s complaint.
60. We hope this reassures Mrs P that if ever her husband’s feeding tube was removed the Trust acted promptly to re-insert it.
Ward
61. Mrs P has raised concerns her husband was not placed on an appropriate ward that could deal with his condition and behaviour.
62. We are sorry to hear of Mrs P’s concerns and understand how worrying this would have been for Mrs P to believe the staff taking care of her husband were not specifically trained to deal with his situation and symptoms.
63. The Trust says within its complaint response Mr P was stepped down from ICU after three weeks on 17 November 2022 to ward 6AB (a stroke rehabilitation ward). The Trust says this was appropriate given his condition and symptoms.
64. The NCEPOD guidance says, ‘Following the initial assessment and treatment of patients admitted as an emergency, subsequent inpatient transfer should be to a ward which is appropriate for their clinical condition; both in terms of required specialty and presenting complaint.’
65. Our physician adviser says whilst the NCEPOD guidance specifically relates to emergency admissions rather than ICU step-down the same principles apply.
66. Mr P had suffered from a hypoxic brain injury and based on his primary needs at the time of transfer our physician adviser says a stroke rehabilitation unit would be the best ward for him to be transferred to.
67. Mr P’s medical records show a neurorehabilitation unit was considered however, this was at a different Trust. Our physician adviser says transfer to a neurorehabilitation unit is not simple and requires specific funding. Therefore, a transfer to such a unit is not appropriate directly from ICU.
68. We consider the Trust acted in line by assessing Mr P’s needs and transferring him to a ward which is equipped and trained to deal with his needs and presenting condition. We have seen no evidence that the stroke rehabilitation ward he was transferred to was not the appropriate ward for Mr P. We consider there is no maladministration here.
69. We hope this reassures Mrs P the staff on the stroke rehabilitation ward were appropriately trained to deal with her husband and his needs and it was appropriate for him to be cared for here.
Security
70. Mrs P has raised concerns the Trust alerted security due to her husband’s behaviour which she feels was not necessary.
71. We can understand how distressing it would have been to witness security being called to attend to your husband.
72. The Trust says, ‘it is important to note that when patients are demonstrating any kind of aggressive behaviour it may be appropriate to call for assistance from security.’ However, it has also said further training has been provided to staff to assist with de-escalation any agitation patients may present with.
73. Mr P’s behaviour has been described as, ‘he was pushing me, get out of room,’ ‘Became physically aggressive’ and ‘rang HOOP to identify what else he can have to maintain his safety and settle him down.’
74. Mr P’s medical records show the Trust gained advice from the enhanced care team (ECT) regarding his agitation. His records show due to his unpredictable behaviour he benefited from the ECT and remained as part of its caseload as a priority patient. The ECT said, ‘If he is unable to be managed at ward level, please utilise security to assist.’
75. The Trust also raised Mr P’s behaviour with the hospital out of hours service (HOOP) and medical staff before calling security.
76. The Trust’s policy says, ‘To be effective, security officers should be engaged with as soon as possible as part of a multi-disciplinary process to deal with violence and aggression on site. Often security officers are contacted when a situation has escalated beyond engaging in conflict resolution techniques.’
77. Based on the above, we consider the Trust called security as a last resort after seeking guidance from other areas of the hospital and other members of staff, and has acted in line with its own policy. We consider there is no failing in this element of the complaint.
78. We understand it was extremely distressing for Mrs P to see her husband have security called when his behaviour escalated. We hope our findings give her some reassurance about why security had to be called and why we consider the Trust only did so once other options had been explored by staff.
Sedation
79. Mrs P has raised concerns her husband was over sedated whilst he was an inpatient at the Trust. We recognise it was worrying for Mrs P to see her husband in this condition and to believe he was over sedated.
80. The Trust says Mr P’s, ‘condition was a very complex one which posed a number of challenges that needed addressing. Unfortunately, he may have lost his appetite because of a result of being given sedation however the investigation had been advised by a nurse consultant that the administration of sedation was unavoidable on occasion and was the right treatment plan’.
81. The Trust prescribed psychotropic medications which included haloperidol, sodium valproate, mirtazapine and lorazepam to manage his behaviour. These are drugs which can affect behaviour, mood, thoughts, or perception. Our adviser says some of which can cause sedation. We also understand the Trust prescribed oxycodone which is an opiate analgesic which is primarily used to manage pain but can contribute to delirium.
82. Our adviser says due to Mr P’s hypoxic brain injury he was at a high risk of suffering from delirium, which is characterised by episodes of restless and agitated behaviour.
83. The NICE delirium guidance says if a person with delirium is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, a pharmaceutical approach can be taken. This is what happened in Mr P’s case.
84. The guidance also goes on to say, ‘When using antipsychotics:
• use the lowest effective dose and use them for the shortest possible time • reassess the person at least every 6 weeks, to check whether they still need medication’.
85. Mr P’s medical records show when a medication was prescribed to help with his delirium, the Trust sought both medical and psychiatry advice. His medical records are also well documented with an explanation as to why the medication was being prescribed and at what dose.
86. We consider psychotropic medications were used rationally and the Trust made attempts to reduce and stop when possible. This is all in line with the NICE delirium guidance and therefore we consider there is no failing here.
87. We hope this reassures Mrs P her husband was not over sedated during his time at the Trust.
Medication
88. Mrs P has raised concerns about the medication her husband was receiving. She feels some medication was prescribed but not administered and she also has concerns that some medication the Trust were administering was not appropriate.
89. We again understand how worrying and upsetting it would have been for Mrs P to feel her husband was both not receiving medication he needed and was being prescribed medication he did not need. We understand this would have led to Mrs P worrying whether her husband’s recovery was hindered.
90. The Trust says within its response, ‘It is difficult to prove or disprove whether staff did not give the patients their medication in a timely manner.’ It also goes on to say, ‘The Nurse Consultant for mental health reviewed the treatment given and advised that your husband was regularly receiving lorazepam, within recommended doses for short-term management of agitation. The 24-hour period on 27th December does exceed the typically maximum recommended dose of 4mg within 24 hours. In psychiatry, much higher doses are used to treat catatonia, but is unlikely in this case’.
91. Our physician adviser says Mr P’s hypoxic brain injury put him at high risk of delirium characterised by episodes of restless and agitated behaviour.
92. The NICE delirium guidance outlines preventative strategies such as addressing environmental, nursing, medical and sensory factors that can contribute to delirium. However, the guidance is clear that if a person with delirium is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, a pharmaceutical approach can be taken.
93. Mr P’s medical records show at times he was at risk of harming himself and others, and experienced periods of severe distress. Therefore, in line with the NICE delirium guidance the Trust prescribed medication to help with his delirium.
94. We understand Mr P was prescribed haloperidol, sodium valproate, mirtazapine and lorazepam during his inpatient stay to help with his behaviour and delirium. These are psychotropic medication and our physician adviser says they were appropriate to help manage Mr P’s behaviour.
95. Our adviser says the NICE delirium guidance quoted in paragraph 84 above is appropriate to use here as it is in relation to the longer term use of antipsychotic medication.
96. Mr P’s medical records show the Trust gained medical and psychiatric advice before prescribing the medication. This is again in line with the NICE delirium guidance.
97. We considered Mrs P’s concerns that the Trust prescribed a medication but did not administer it. Mrs P was unable to recall the name of this medication but told us it was prescribed to her husband when his NG (naso-gastric – feeding) tube was not in. Mrs P says the medication should have been prescribed during this time but it was not.
98. We have been unable to determine which medication Mrs P feels was not administered correctly when her husband’s NG tube was not inserted. Our physician adviser also reviewed the notes to establish which medication Mrs P was referring to but was unable to find anything relevant.
99. Mr P’s medical records show he was first admitted to the Trust in the early hours of 25 October and was in triage at 4.51am. The records show by 5.48am an NG tube had been inserted and he was prescribed aspirin and ticagrelor, which is an antiplatelet medication.
100. This is in line with the NICE ticegralor guidance says ticagrelor should be prescribed with a low dose of aspirin for patients who are suffering from chronic coronary syndromes.
101. We therefore consider Mr P has received essential medication within an hour of admittance.
102. To also offer some reassurance to Mrs P, whilst we cannot determine which medication she is concerned about, our physician adviser said all essential medications were provided to Mr P either by NG tube or by IV. We have been unable to find any issues with essential medications being missed or not being administered appropriately and so have fund no failing here.
103. We hope this offers Mrs P some reassurance.
One to one care
104. Mrs P has raised concerns her husband did not receive the one to one care and support he needed during his time as an inpatient.
105. We understand Mr P had a lot of needs due to his hypoxic brain injury and for Mrs P to feel he was not receiving the appropriate one to one care and support he needed must have been extremely distressing.
106. The Trust says when a patient meets the criteria for one to one care appropriate steps should be taken to ensure this is provided. The Trust also says, ‘The patient’s story to be shared with staff across Ward 6 AB to highlight the need to ensure 1:1 care is appropriately managed’.
107. Our nursing adviser says there is no national guidance about one to one care. They add the aim of one to one nursing is to provide continuous observation for an individual patient for a period of time during acute physical or mental illness. This deprives patients of their privacy, and alternative strategies should be explored before one to one is put in place.
108. Mr P’s medical records show following an MDT (multi-disciplinary team) meeting before he was moved to the stroke rehabilitation ward, it was agreed Mr P should receive one to one care. Mr P was assessed as requiring one to one support because he was a risk to himself and others.
109. This was discussed with Mrs P which is in line with the NMC guidance which says, ‘share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’.
110. Mr P’s medical records show a Deprivation of Liberty Safeguards (DoLS) was also completed which means he was under continuous supervision, was not free to leave and lacked the mental capacity to consent to their own treatment. Our nursing adviser says this applied to Mr P.
111. We understand the Trust told Mr and Mrs P about the DoLS and why this application was required. The Trust also arranged for a specialist doctor and Best Interests Assessor (BIA) to assess Mr P. This is in line with the DoLS guidance.
112. We consider, the Trust appropriately provided one to one care to Mr P and competed a DoLS, to safeguard him while he was continually supervised and received the appropriate care and treatment he needed. We therefore believe there has been no maladministration in this part of the complaint.
113. We aim in our explanation to give Mrs P reassurance about what care and supervision her husband received whilst he was an inpatient at the Trust during this period.
Delays
114. Mrs P has raised concerns there was a delay with her husband’s X-ray results. We recognise this was worrying for her.
115. We understand Mrs P’s concerns about her husband’s X-ray results were from when he was transferred to the ward, we have therefore focused on any X-rays completed between 18 November 2022 and 30 January 2023.
116. The Trust says it is, ‘very sorry that you were inaccurately advised that your husband had not been for an X-ray, or that there was any delay in communicating the results to you’.
117. Mr P’s medical records show he had two X-rays completed on 18 November, one on: 6 December, 21 December, 5 January, 12 January and 16 January. All of these X-rays apart from the one carried out on 16 January were to check Mr P’s NG tube had been inserted correctly. The X-ray completed on 16 January was a chest X-ray to see if Mr P had developed hospital acquired pneumonia.
118. The GMC guidance says, ‘promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.
119. Our physician adviser says X-rays are carried out based on whether the request is emergency, urgent or routine. They added as most of Mr P’s X-rays were to check the positioning of his NG tube, this would not be an emergency and therefore Mr P would be placed on a waiting list for the X-ray to be completed.
120. We have not seen any evidence to suggest the X-rays were not carried out within an appropriate timescale.
121. With regards to the X-ray results, our physician adviser says most X-rays do not need to be reported or looked at by a specialist team. This is especially true in this case, as the X-rays were checking the location of the NG tube this would have been looked at by the doctor at the time the X-ray was taken. Therefore, there would be no waiting for a report or results.
122. We have seen no evidence there was a delay with results following an X-ray during this time. We consider there is no indication of a failing here.
123. Our physician adviser comments Mr P received prompt and good quality care during his admittance. We hope this helps to reassure Mrs P in some way.
Neurology
124. Mrs P has raised concerns her husband was not seen by a neurologist.
125. We understand why Mrs P’s believes a neurologist should be involved in her husband’s care given he had suffered a hypoxic brain injury and recognise she has questions why this did not happen.
126. The Trust says, ‘After various investigations, it was found the patient had suffered Hypoxic brain injury. Hypoxic brain injuries are injuries that form due to a restriction on the oxygen being supplied to the brain. The restricted flow of oxygen causes the gradual death and impairment of brain cells, which is irreversible.’
127. Mr P’s medical records show he suffered from a hypoxic brain injury following him being found unresponsive with abnormal breathing. From our understanding there is no question or concern this diagnosis is wrong. Therefore, our physician adviser says after this diagnosis the next step is managing Mr P’s behaviour and taking a multidisciplinary rehabilitation approach. We consider this is what happened.
128. Mr P’s medical records show a neurologist did perform an electroencephalogram (ECG) when he was first admitted to the Trust. The results to this showed no further involvement was needed by a neurologist. There is no specific guidance relevant here.
129. Hypoxic brain injury is irreversible therefore once the neurologist diagnosed Mr P there was no treatment they could provide to help better this.
130. We therefore consider Mr P did not require input from a neurologist as a diagnosis had already been made. There is no evidence of maladministration in this element of Mrs P’s complaint. We hope this gives Mrs P a clear explanation.
Thrush infection
131. Mrs P has raised concerns the Trust did not appropriately treat her husband’s thrush infection, caused by his feeding tube. We are sorry to learn of Mr P’s infection and Mrs P’s worry about this.
132. The Trust says feeding tubes are very difficult to insert but it did not identify any issues with the insertion or working of Mr P’s tubes.
133. Mr P’s medical records show a number of concerns raised by his family about his feeding tube. We can also see from his records that the Trust acknowledged these concerns, investigated them and when oral thrush was identified it was raised with the appropriate medical staff.
134. Mr P’s medical records also show when he was unable to tolerate the liquid medication for his oral thrush, the Trust escalated this and made sure he was prescribed tablets.
135. The NMC guidance says, ‘13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care 13.2 make a timely referral to another practitioner when any action, care or treatment is required 13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence.’
136. We consider the Trust acted in line with this guidance when it identified Mr P was suffering from oral thrush.
137. The RPS guidance also says, ‘When a medication is not administered or refused, details of the reason why (if known) are included in the record and, where appropriate, the prescriber multidisciplinary team is notified in accordance with the organisational policies and procedures. Appropriate action is taken as necessary.’
138. This again shows the Trust acted appropriately and in line with this guidance when treating Mr P’s oral thrush.
139. We consider there is no indication of a failing in this part of the complaint and Mrs P can be reassured on this matter.
Handovers
140. Mrs P has raised concerns the Trust did not handover her husband’s care appropriately.
We are sorry to learn about Mrs P’s concerns and can understand why this caused worry and distress for her.
141. The RCP guidance says: ‘Handover has several purposes:
1. To ensure that changes in the clinical teams responsible for providing care are not detrimental to the quality of healthcare that a patient receives.
2. To improve communications between all members of the health care team and with the patient and his/her family.
3. To ensure recognition of unstable and unwell patients and that their management remains optimal and is clear and unambiguous, and by that process to improve patient outcomes.
4. To improve efficiency of patient management by clear baton passing.
5. To improve patient experience and confidence.’
142. Our nursing adviser says a handover is performed when the responsibility for immediate and ongoing care is transferred between healthcare professionals, usually at shift changes. At every handover staff will discuss a number of different patients and therefore it is not documented within a patient’s medical records.
143. Mr P’s medical records however, do contain notes such as ‘Handover given to ward 6’. Therefore, we consider handovers did take place. Whilst we do not know what was discussed, we do not consider there is any maladministration here as there is evidence handovers have taken place. We again hope this reassures Mrs P that whenever there were staff changes, they had been updated about her husband.
Communication
144. Mrs P has raised concerns there was a lack of communication between the Trust and herself. We recognise this must have been upsetting and distressing for Mrs P whose husband had bene through a traumatic and life changing medical event.
145. The Trust says, ‘Staff should ensure that they provide patients and their relatives with accurate information, and I am very sorry that this the communications fell below the expected standard on this occasion’. This was regarding Mr P’s NG tube feeding not being in place.
146. The GMC guidance says, ‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
147. Mr P’s medical records show a number of conversations between Mrs P and different members of staff from his admission in ICU to the stroke rehabilitation ward. There is evidence of frequent and multidisciplinary discussions with Mr P’s family including his wife.
148. On several occasions it is clear Mrs P found the information she was receiving to be difficult to process. Our physician adviser says the notes evidence the Trust provided support and was sensitive in how it communicated with Mrs P which is what is expected and in line with GMC guidance.
149. We also consider when the family raised concerns, the Trust acted quickly, and safeguarding referrals were raised where appropriate.
150. Overall, we have not seen any evidence to suggest the Trust did not communicate with Mrs P in an appropriate and timely manner. We again consider there is no maladministration in this part of the complaint.
151. Mr and Mrs P have been through a terrific ordeal and we recognise it has been life changing for them both and their family. We thank Mrs P for sharing detail with us of such a worrying and distressing time and allowing us an opportunity to consider her complaint.