The Princess Alexandra Hospital NHS Trust

4. Mr P complains about the care the Trust provided for his late mother-in-law, Mrs K. Mrs K was admitted to the Trust on 30 November 2022. Mr P complains the Trust:

• failed to provide appropriate hygiene and bed care due to understaffing • failed to investigate, correctly diagnose and treat the cause of Mrs K’s deterioration on 10 December • mistakenly provided a syringe driver and morphine and did not remove this immediately when it was discovered • discharged Mrs K to a facility which could not properly manage her needs.

5. Mr P says because of staffing issues, Mrs K was left in wet bedding. This caused her to develop sores and infections. He says the causes of Mrs K’s deterioration were never properly established and treated. This led to her further decline.

6. As a result of the syringe driver, Mr P says Mrs K cognitively declined and never regained the same level of cognitive awareness again. He says the above issues contributed to a weakening of Mrs K’s condition and ultimately led to her death.

7. He says as a result of a poor discharge choice, Mrs K’s condition was not properly monitored, and she died alone and without proper management of her symptoms.

8. As a result of his complaint, Mr P would like the Trust to provide a detailed apology, make service improvements and provide a level six financial remedy.

9. Mrs K was an 84-year-old woman with a history of high blood pressure, anxiety and depression, an irregular heart rhythm (atrial fibrillation), paraproteinemia and hyper cholesterol. Paraproteinemia is caused by the body producing an abnormal protein. It is a condition which can lead to the development of cancers. Hyper cholesterol is when bad cholesterol levels are too high in the body.

10. On the 27 November 2022, Mrs K was admitted at the Trust. She had recently suffered a number of falls. After her last fall, she vomited a coffee ground-like substance. The Trust suspected she may have an upper gastrointestinal bleed.

11. The Trust initially scanned Mrs K to check if she had suffered a stroke. It found no evidence she had. On the 30 November, the Trust diagnosed Mrs K with a urine infection and provided IV antibiotics. It also provided an X Ray and noted she had a lumbar fracture.

12. In December, Mrs K began refusing meals and suffered with stomach pain. Later she began to decline oral medications and reported feeling something was stuck in her sternum. The Trust diagnosed her with pneumonia.

13. On 9 December, Mrs K became drowsier and weaker. The next day Mrs K became unresponsive. The Trust made a provisional diagnosis of stroke and ordered scans. The Trust determined Mrs K was in end-of-life and put together an end-of-life plan. On the 12 December the results of a scan showed that Mrs K had not suffered a stroke.

14. On 13 December, the Trust put a syringe driver in place, to help manage Mrs K’s pain as she was deemed to be actively dying. On 14 December, Mrs K recovered and woke up. The Trust reversed its end-of-life treatment plan.

15. Between 15 and 19 December, the Trust provided ongoing review and care for Mrs K. Mrs K developed swollen arms and bloodied lips between 21 and 22 December. The Trust considered possible heart failure and liver cirrhosis, as possible causes. Liver cirrhosis is when the liver has become severely scarred. The scarring negatively impacts the function of the liver and can lead to liver failure.

16. On 27 December, The Trust inappropriately restarted morphine administration via a syringe driver. On the 28 December, Mrs K deteriorated. The syringe driver was found to be running when it should not have been and a Datix was flagged. Datix is a system used in the NHS to report serious incidents. The Trust stopped the morphine pump.

17. The Trust discharged Mrs K on 1 January to a care home. Very sadly, Mrs K died in the care home on 8 January 2023.

Hygiene and Bed care

21. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have found some indications of failings.

22. Our Service Model Guidance explains if we can deliver the outcomes a complainant asks us to achieve at an earlier point in our case handling process, we can do so. This is what we have done for these issues. We have agreed with the Trust a series of remedies to put right the issues we think there are indications of failings on. For this reason, we will not be taking the complaint to a detailed investigation.

23. Mr P says that when the family visited Mrs K, she was often in wet bedding. He says the family had to repeatedly request that her bedding and pads were changed. Mr P believes this led to Mrs K developing sores.

24. In response to the complaint, the Trust said that it was understaffed, and the ward manager was struggling. It said new managers and staff were hired. The Trust also accepted Mrs K had not been repositioned often enough.

25. The relevant clinical standard for this issue is NICE CG138. It says, ‘There should be recognition of …the importance of meeting fundamental needs..,’ and this includes, ‘personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed.’

26. The NMC’s ‘The Code’ also says nurses should, ‘Keep clear and accurate records relevant to your practice.’ It also says, ‘identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who use the records have all the information they need.’

27. The guidance tells us that the Trust should have met Mrs K’s continence needs and kept her hygienic and comfortable. Nurses should have also recorded how to manage Mrs K’s bed care and communicate with other staff when there were issues.

28. Our nursing adviser also told us the Trust should have calculated Mrs K’s waterlow score and assessed how often she should have been monitored. A waterlow score is a tool used to assess the risk of a patient developing sores or ulcers. The score and assessment should be noted in the records for other staff to see. Evidence of bed monitoring at the right intervals, should also be documented in the records.

29. Our nursing adviser explained Mrs K’s initial score meant the Trust should have repositioned and changed her pad every four hours. When her score increased, this frequency should have changed to two to three hourly. Our nursing adviser said the records show this was adhered to frequently, but there were also many periods when it was not. This is not in line with the NICE standard above.

30. Our nursing adviser also pointed out that Mrs K’s waterlow score and the frequency of skin checks needed, were not always written down on the daily sheets. They said the Trust should have also noted when Mrs K’s positioning and changing needs had not been met. This was not always done.

31. We understand how distressing it can be to leave a loved one in the care of another. For the family to discover, on more than one occasion, that Mrs K was in wet bedding must have been very upsetting for the family. We were sorry to hear they had cause to be worried about this and understand how frustrated they must have felt when she went on to develop bed sores.

32. We can see the Trust has already acknowledged some failings in this area. It has explained to Mr P that new staffing is in place, which should enable nurses to meet the requirements of their patients. However, we think the Trust have not acknowledged the issues with documentation in the notes. We think it could take more action to ensure documentation takes place correctly. We will explain what we think the impact of this is and our recommendation below.

Deterioration on 10 December

33. Mr P says once Mrs K lost consciousness on 10 December, the Trust never confirmed what caused her to become unresponsive. He says the Trust ruled out stroke but then no other investigations were done to understand what caused her to deteriorate.

34. NICE clinical knowledge summary on Stroke and TIA says to suspect stroke if the person has a sudden focal neurological deficit which cannot be explained by another condition.

35. NICE standard NG31 says clinicians should assess a patient for any signs they are entering end-of-life. This may include lowered level of consciousness.

36. The guidance says to notice signs the patient is stabilising again and avoid investigations for patients in end of life. It also says to be vigilant to changes in the patient and monitor them every 24 hours, updating their care plan as required.

37. GMC standards say clinicians should ‘adequately assess the patients’ conditions, taking account of their history’ and ‘promptly provide or arrange suitable advice, investigations or treatment where necessary.’

38. We asked our geriatrician adviser if the Trust acted as it should have done, in relation to the above standards. They said it was appropriate for the Trust to consider Mrs K had suffered a stroke on 10 December. This is because she suffered a rapid decrease in consciousness and had increased risk factors for stroke. This is because she was taking blood thinners for her atrial fibrillation. The Trust made an appropriate provisional diagnosis consistent with NICE guidance on stroke.

39. The Trust deemed Mrs K to be in end-of-life when she became unresponsive and had lowered consciousness. This is consistent with standards in NG31. Because the Trust determined Mrs K was in end-of-life it was appropriate for the Trust to stop testing and active treatment. The guidance tells us, when a patient is in end-of-life this should happen, and professionals should focus on making the patient comfortable. The Trust provided a morphine pump, which would have assisted in making Mrs K comfortable.

40. We know the Trust did a CT scan which showed ‘no intracranial abnormalities’. We understand that Mr P feels the Trust should have then done further tests to understand why she was now unresponsive. However, we can see it was not appropriate for the Trust to do this, while Mrs K was still deemed to be in end-of-life. Further investigation at that time, would not have been appropriate.

41. Mrs K recovered on 14 December. The Trust reassessed Mrs K and began further treatment.  It performed blood tests and provided antibiotics and fluids. These were to help investigate her condition and manage her suspected chest infection. The Trust also provided an echocardiogram to check the function of Mrs K’s heart and referred her to a Gastroenterologist.

42. We can see these actions are in line with NG31 as the Trust noticed Mrs K had stabilised and updated her care plan. The Trust began to do further tests in line with GMC guidance to assess patients and provide relevant tests and treatment.

43. As a result of investigations by the gastroenterologist, the Trust identified Mrs K had liver cirrhosis. Our adviser explained, by the time she was diagnosed, there were cellular changes in Mrs K’s liver which were irreversible. This meant that her cirrhosis could not be treated. The Trust considered her to be in end-of-life at this point because her liver cirrhosis was advanced. Our adviser, said this was appropriate.

44. We can see the Trust acted in line with GMC standards once she recovered from her period of unconsciousness. The Trust investigated Mrs K’s condition and provided treatment for infection.

45. Our geriatrician adviser informed us the Trust did not act as it should have when it made Mrs K’s liver cirrhosis diagnosis. They said the records do not show that a full and frank discussion about the diagnosis were had with Mrs K or the family.

46. NG31 guidance says a dying person's prognosis should be discussed with them straight away, and with any important friends or relatives. It also says accurate information should be given about prognosis and space made for the patient and family to ask questions.

47. We have considered what our adviser said about failures in communicating a terminal diagnosis. The family have told us that throughout Mrs K’s care it was unclear to them, whether Mrs K was in end-of-life. They also told us that failings to investigate her collapse on 10 December led to her decline and death.

48. Our adviser said that Mrs K’s deterioration was almost certainly linked to her liver cirrhosis. Liver cirrhosis is hard to detect and often goes undiagnosed until it is too late. Given the nature of the family’s complaint, their confusion about whether Mrs K was in end-of-life and the lack of discussion documented in the records, there indications of failings to communicate the end-of-life diagnosis to Mrs K and her family. This is not in line with NICE NG31 standards. We will consider impact and recommendations below.

Morphine Pump

49. Mr P says on 27 December, the family found Mrs K unconscious again. There was a morphine pump in her bed and morphine had been given. He says Mrs K deteriorated after this, probably because of the morphine.

50. The Trust said the issue should not have happened and it was raised as a clinical incident. It has spoken to the team involved and the pharmacy. The pharmacy now provides additional checks before dispensing medication. The nurse who administered the morphine was also spoken with.

51. GMC standards say clinicians must only ‘prescribe drugs…when you…are satisfied that the drugs or treatment serve the patient’s needs.’ Our geriatrician adviser said when the morphine was initially prescribed, it served Mrs K’s needs because she was considered to be in end-of-life. However, once she recovered, she was no longer in need of morphine and therefore the prescription did not meet her needs. The medication should have been removed from the prescriptions list. We recognise this is an indication of a failing to meet the GMC standard.

52. We understand the Trust accepted this as a failing, apologised and made service improvements. However, Mr P says that the issue had a more serious effect on Mrs K, as she never gained full neurological awareness after this. He believes it was a contributing factor to her death.

53. We asked our geriatrician adviser, if the administration of morphine could have contributed to Mrs K’s decline or death. They said the only significant side effect of morphine is lower levels of consciousness. Morphine is generally out of a person’s system within 24 hours. They explained the morphine would have made Mrs K drowsier for up to 24 hours after the pump was stopped. But it would not have contributed to her overall decline. They pointed out that the medical records show by 29 December Mrs K was alert again. This shows the morphine did not have a lasting impact on Mrs K.

54. Considering this advice, we do not think the failing of inappropriately providing morphine, contributed to Mrs K’s death. We recognise that the Trust have accepted there is a failing on this issue. We think it has taken some appropriate action. However, we do consider there is some emotional distress for the family which could further be remedied. We will explain this further below.

Discharge

55. Mr P believes the Trust discharged Mrs K unsafely because it made an error by giving her the morphine pump.  He says Mrs K was taken to a care home which could not manage her needs, and she suffered an undignified death.  We can understand Mr P’s feeling on this matter, and why he has felt concerned about the timings of discharge. We were also sorry to hear from Mr P that Mrs K had an unpleasant and unpeaceful time during her final days.

56. DHSC (above) guidance outlines when a fast-track referral should be made. It says, ‘individuals with a rapidly deteriorating condition and who may be entering a terminal phase, may require ‘fast tracking’ for immediate provision of NHS Continuing Healthcare.’ The purpose of the fast-track pathway is to enable patients to get ongoing care from the NHS, outside of a hospital setting, with no delay.

57. The guidance also says it is the responsibility of a clinician to decide if the patient meets the criteria for a fast-track discharge.

58. Our geriatrician adviser said by the time the Trust prepared Mrs K for discharge, she had no acute care needs. This means she did not need any further input from the clinical team. She was also in end-of-life stages and therefore the focus of her care, should have been maintaining her comfort. The Trust should not have provided further investigations or active treatment.

59. The Trust knew Mrs K had liver cirrhosis, and she would very likely die from this. We can see that the next steps for her would be to receive end-of-life care in an appropriate, and non-acute environment. Based on the guidance above, we can see Mrs K was an appropriate candidate for a fast-track referral.

60. We can also see in the records that the Trust repeatedly considered when it could discharge Mrs K. Prior to the morphine pump incident, discharge was considered on 6, 19 and 22 December. We can see no evidence that the Trust only considered discharging Mrs K once it had made a mistake or that the discharge was unsafe.

61. We explained to our adviser that Mr P believes Mrs K was not discharged to an appropriate facility, and that she was unable to have IV fluids, and died on her own. Mr P says she should have been discharged to a hospice.

62. Our geriatrician adviser explained that a hospice is a place where patients with complex needs can access the right interventions and care. While Mrs K was correctly noted to be in end-of-life, her symptom management and comfort needs were not complex. They explained that nursing homes are equipped to manage end-of-life patients.

63. They said Mrs K was discharged with anticipatory medications to prepare for the event of reaching her final hours. Our adviser explained that IV fluids would not have prolonged Mrs K’s life or added to her comfort. They said when patients are dying, they are often not thirsty because their bodies are sadly shutting down. Had Mrs K wanted a drink, she was noted by the Trust to be able to drink independently, so her comfort was not compromised.

64. We consider the Trust acted appropriately by instigating a fast-track discharge for Mrs K. She fulfilled the criteria for this. She was also an appropriate candidate for nursing home care as her needs were not complex. There are no indications of failings on this issue.

Impact

65. We consider there are indications the Trust failed to document Mrs K’s waterlow score, position and change needs consistently in the daily nursing rounds. We also consider nurses did not attend to Mrs K frequently enough to meet her comfort, continence and hygiene needs. Mr P told us that Mrs K developed sores, from being in wet bedding.

66. We asked our clinical adviser if the sores were preventable. She explained had Mrs K been seen with the appropriate frequency, on the balance of probabilities she would not have developed sores. We think the impact of this issue, is discomfort and pain for Mrs K as well as distress for the family in witnessing her in the wet bedding and in discomfort and pain.

67. We also consider there are indications the Trust failed to communicate properly about Mrs K’s liver cirrhosis. This has caused confusion for the family about if she was deemed to be end-of-life and why she deteriorated. We do not think the family were not fully aware of how seriously ill Mrs K was. We think the impact of this issue is distress for Mrs K’s family.

68. We also consider there are indications of failings to appropriately prescribe and administer drugs which served the patient’s needs. We do not think the impact of this issue contributed to Mrs K’s decline. We do think it caused the family distress and compounded their fears that their mother was not in a safe environment or being cared for appropriately.

69. Overall, we can see that in addition to issues already accepted by the Trust (bed care and morphine pump) there are additional communication issues. This includes failure to communicate between nurses in documentation and daily rounds, and failures to communicate with the family about Mrs K’s diagnosis. We consider these issues have contributed significantly to the distress and grief of Mrs K’s family. It also contributed to Mrs K’s discomfort and pain.  Remedy

70. As outlined above, our Service Model Guidance explains we can achieve the outcomes a complainant asks for, at an earlier stage in our process. This is if it helps resolve the case in a more time-efficient way for the complainant.

71. We have spoken to the Trust about the issues we have seen with communication, providing appropriate bed care, and the morphine pump issue. We have explained that while the Trust have taken some action to remedy the bed care issues, we think there are further issues with communication which it can acknowledge and a financial remedy it can pay, as requested by Mr P.

72. In addition, we have explained that we understand the Trust has taken action on the morphine pump issue and apologised for this. However, we think there is more the Trust can do to remedy the distress this has caused.

73. We have also explained to the Trust the noted failing about communicating an end-of-life diagnosis, and that we think it could take action on this issue.

74. In light of our assessment, we have asked the Trust to: • apologise for issues in communicating with the family and documentation in the daily rounds • make improvements in nursing documentation of bed care and communication in nursing handovers • make improvements in communicating end-of-life diagnosis • pay a financial remedy to the family.

75. The Trust have agreed to take these actions to resolve the complaint and remedy the issues we have seen indications of failings on.

Financial Remedy

76. When we recommend a financial payment we consider the appropriate amount, in line with our Severity of Injustice Scale. As Mrs K has sadly died, we can only remedy the distress caused to the family. We recognise seeing Mrs K in wet bedding and the morphine pump issue, caused the family distress. Failure to explain details of Mrs K’s liver cirrhosis diagnosis caused more serious distress as it has led the family to think her death may have been preventable. Following clinical advice, we now know that was not the case.

77. The distress caused to the family is consistent with level three on our scale. This is because it relates to both ‘distress…lasting 6-12 months’ and ‘single…highly distressing experiences where there are no other significant adverse impacts.’ We think the morphine issue relates to a single, distressing incident, and ongoing distress for up to a year, was caused by communication issues. We have asked the Trust pay £600 to Mr P, in light of this impact.

78. We would like to thank Mr P for bringing his complaint to us. We understand Mrs K suffered during her time at the Trust and problems with personal hygiene and bed care, were distressing for her and the family. We also recognise these issues caused the family significant distress as they believed the Trust’s actions contributed to Mrs K’s death.

79. We hope our investigation brings some reassurance to the family that issues in care, did not contributed to Mrs K death. However, where we have seen indications of failings, we hope the remedy we have agreed brings some comfort. As a result of his complaint, Mr P has helped to identify some issues which were not previously clear and to improve services at the Trust.

80. We thank Mr P for giving us the opportunity to independently review the complaint and do our work in improving standards in public health care.

1. We have carefully considered Mr P’s complaint about the Trust. We were sorry to hear about the loss of Mrs K who was clearly much loved by her family. We were sorry to hear the family’s grief was clouded by distress that she received poor care.

2. We saw indications of failings to provide appropriate bed care, failures in the process of investigating Mrs K’s deterioration and mistakenly providing a syringe driver. We did not see indications of failings in the Trust discharging Mrs K.

3. We think the impact of failings led to Mrs K developing bed sores and worry and concern for the family. We have not seen that any of the indicated failings led to Mrs K’s death. We have agreed a resolution with the Trust to remedy these issues.