University Hospitals Birmingham NHS Foundation Trust

4. Mrs O complains about aspects of care provided to her father, Mr E, by the Trust during his admission in 2024. Specifically, she complains:

• the Trust was not clear with the family if a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) was in place or not during his admission • when her father began dying, the Trust stated Mr E had a DNACPR in place and only began commencing cardiopulmonary resuscitation (CPR) because the family was distressed. The Trust delayed commencing CPR for seven minutes.

• the Trust kept sedating Mr E for no reason • the Trust did not communicate the care Mr E was receiving with his family • the Trust cared for Mr E with a lack of dignity leaving him on a ward bed naked without any privacy

5. Mrs O says the Trust missed signs of deterioration because it sedated Mr E for no reason. She believes Mr E would have received more appropriate care and survived if the Trust had not done this. Mr E’s family also feel he was being kept like an animal and had no dignity while he was under the care of the Trust. They feel the failings by the Trust led to his death.

6. Due to the lack of communication around the care Mr E was receiving, his son left to go back home to America and missed the opportunity to spend the final days by his father’s side.

7. As an outcome to this complaint, Mrs O would like an acknowledgement of failings, an apology and a financial remedy.

8. In April 2024, Mr E was admitted to the Trust.

9. Three days after the Trust admitted Mr E it put a plan in place to discharge him. That plan changed because Mr E’s blood test result showed a new onset of Acute Kidney Injury.

10. Mr E’s condition deteriorated the following day. The vascular registrar reviewed and managed Mr E, along with a number of other senior doctors from other specialities. The vascular registrar undertook an assessment that afternoon, and the Trust decided to admit Mr E to ITU. The registrar also discussed Mr E’s condition with his family. They also discussed issues with Mr E’s heart and his resuscitation status.

11. That evening, the Trust’s renal team reviewed Mr E. The renal doctor discussed their assessment with the family and explained Mr E’s kidneys were failing and he may not recover. The renal doctor explained Mr E was critically unwell, he may not survive and the issues around Mr E’s resuscitation status were again discussed.

12. Shortly after Mr E was transferred to ITU he suffered a cardiac arrest. The Trust performed resuscitation, which was successful. The Trust started Mr E on renal replacement therapy (dialysis). Dialysis is a procedure to remove waste products from the blood when the kidneys are not working properly.

13. The following day, The Trust discussed clinical issues and ITU care, including the fact Mr E was critically ill, with the family. Over the next few days, the Trust held multiple discussions with Mr E’s family. This was in relation to the futility of doing CPR. It was agreed that he would not be suitable for CPR in view of his overall poor health status and multiple health conditions.

14. 20 days after Mr E had been transferred to ITU, the Trust moved him to a ward. Three weeks later, the Trust examined Mr E because of a headache. The Trust did not find any signs to suggest anything alarming. The Trust planned to administer paracetamol that day, and if Mr E’s headache did not settle, the Trust planned to arrange a CT scan of his head the next day.

15. The following day, the Trust reviewed Mr E and he reported no headache. During that day, Mr E’s family reported to the nursing staff, that he had a headache. When a nurse approached him multiple times, he denied having a headache and declined paracetamol.

16. Two days later, Mr E’s condition deteriorated and he sadly died.

20. 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 not seen any indication that something has gone wrong.

Communication about a DNACPR decision

21. Mrs O complains the Trust was not clear with her and her family if a DNACPR was in place or not during Mr E’s admission.

22. The Resuscitation guidance provides guidance on this area and this is underpinned by the GMC guidance relating to CPR. The Resuscitation guidance says a decision not to attempt CPR is ultimately a medical decision but needs to be communicated with the family. The guidance specifically states if there is no realistic chance that CPR could be successful then a decision should be made not to attempt CPR.

23. We can see from the records Mr E was seen by numerous doctors who all felt a decision not to attempt CPR was the correct clinical decision. This is because the Trust felt CPR would be futile due to Mr E’s multi-organ failure.

24. The records show numerous discussions between Mr E’s family and the medical team. In the records, the medical team referred to performing ‘limited CPR’. Our adviser said restricted CPR is sometimes carried out in an intensive care setting. We can understand this term may have caused Mrs O and the family confusion as to what Mr E’s CPR status was.

25. We can see in the Trust’s complaint response it acknowledged its communication could have been better relating to this matter.

26. Apart from this, we can see from the records the Trust did broadly act in line with guidance. The Trust discussed its thinking around attempting CPR with Mr E’s family. These discussions were carried out by consultants (the most senior members of the team) and they have been documented clearly.

27. Although the ‘limited CPR’ discussion may have caused some confusion, overall we have seen no indication of failings in the Trust’s actions. We do not think the Trust’s actions have fallen below the standard of care outlined in Resuscitation guidance when communicating Mr E’s DNACPR status with Mrs O or the family.

28. We acknowledge this was a very difficult time for Mrs O and her family, and we hope our decision does not add to the distress she has experienced.

Delay in commencing CPR

29. Mrs O complains when her father began dying, the Trust stated Mr E had a DNACPR in place and only began commencing CPR because the family was distressed. She says the Trust delayed commencing CPR for seven minutes.

30. We can see from the records a DNACPR recommendation was in place at this time. This was in place from mid-April, and it was still in place at the time of Mr E’s death.

31. Our adviser explained a DNACPR document is ultimately an advisory document. On the form where it states that CPR is ‘not recommended’, that is not binding on the medical team. In the event of cardiac arrest, CPR could be commenced but this would be in the most exceptional circumstances and would be based on clinical judgment.

32. We acknowledge the medical team at the time were in a very difficult position and had to act quickly. We can see from the records a DNACPR was ‘not recommended’ and the medical team exercised its clinical judgment by commencing CPR and overrode this recommendation.

33. Our adviser commented the team acted reasonably given the situation. It is clear if the medical team had not started CPR, this would have added to the family’s distress.

34. In relation to the time taken to start CPR, we can see the medical team did delay commencing CPR. This is because CPR was not started until Mr E’s family began expressing distress that the team had not started CPR.

35. Our adviser said this delay did not cause any impact on Mr E’s eventual outcome. Mr E was at the end of his life, and the outcome would likely have been the same. Our adviser explained CPR would have been futile, even if it had been commenced as soon as Mr E went into cardiac arrest.

36. The DNACPR is an advisory document and the Trust used its clinical judgment to override this, which it is allowed to do. We have therefore seen no indication of a failing in the Trust starting CPR. We have also seen no indication of a failings in the delay in starting CPR, as the Trust acted after witnessing the distress of Mr E’s family.

37. We acknowledge Mr E’s deterioration and cardiac arrest was distressing for his family to witness and we are sorry they had to experience such a situation.

Sedation

38. Mrs O complains the Trust kept sedating Mr E for no reason. Because of this, she says the Trust missed signs of Mr E’s health declining.

39. The NICE guidance around delirium sets out when a patient should be sedated. It says sedation should be used on a patient as a last resort if the patient is a risk to either themselves or others.

40. When Mr E was in intensive care he was full sedated. Our adviser said patients who are in intensive care are usually fully sedated and are monitored more closely by staff, often on a one-to-one basis. Machines are also in place to monitor and measure numerous parameters of a patient as well as Trust staff undertaking frequent blood tests.

41. From the records, we can see Mr E was very agitated and hitting out at staff so the use of sedation would appear to be in line with the NICE guidance.

42. When Mr E was on the ward, he was not fully sedated but receiving a sedating medication (Olanzapine) this was to manage his behaviour. Olanzapine is an antipsychotic medication and can be sedating. Our adviser said the standard practice here is to use the lowest dose possible which is what the Trust did.

43. From the records, we can see this drug was reviewed by the Trust psychiatrist who advised that this drug should be continued in Mr E’s treatment. We can also see from the records the Trust sought expert advice from the psychiatry liaison service in relation to the medication. This included reviewing the dose and putting a plan in pace to review the medication. This shows the Trust sought expert advice and our adviser confirmed followed good practice.

44. After reviewing the records, our adviser confirmed Mr E was not overly sedated during his admission. We can see that at one point, as his medical condition improved, the Trust gradually lifted off sedation. As there is no indication the Trust overly sedated Mr E, our adviser said if he did make any improvement this would not have been missed by the Trust.

45. It seems the Trust sedated Mr E in line with the NICE guidance and there is no evidence the Trust over sedated Mr E. We understand Mrs O is concerned the Trust may have missed any signs of improvement due to the sedation. We have seen no indication of a failing in the Trust’s actions in sedating Mr E. We hope this provides her with some reassurance.

Communication

46. Mrs O complains the Trust did not communicate the care Mr E was receiving with his family.

47. The GMC guidance states that families should be involved in discussions and supported.

48. The records suggest the Trust communicated with Mr E’s family about his care before he went to intensive care, while he was there, and while he was on the ward. The records show there were several discussions between Mr E’s family and the most senior members of the medical teams (consultants).

49. The records suggest the Trust explained to Mr E’s family in mid-April that although some blood tests had shown positive signs, he was still very poorly and things could get worse.

50. The records show Trust explained to Mr E’s family his kidneys were not functioning well and he needed dialysis. There was a buildup of acid in his blood which may cause issues with the other organs in his body, and he was receiving treatment for this. The Trust also explained to Mr E’s family he was on medication and antibiotics to treat an infection which it could not locate the origin of.

51. We can also see from the records, the Trust informed Mr E’s family he was at risk of another cardiac event, given his cardiac history. The Trust also informed them there was a high chance Mr E would not get better.

52. When the Trust were considering discharging Mr E, his delirium became a concern for his family and they had a discussion around this with the Trust. A few days later, the Trust also discussed with Mr E’s family why he needed an MRI scan. This was because the Trust were concerned Mr E may have reduced blood flow to his brain after his cardiac arrest.

53. Within these discussions, we think it is likely the Trust explained Mr E’s ongoing issues. This included the acid build-up in his blood due to how his kidneys were functioning, and the problems with some treatment options due to his frailty and other organ issues. We think the Trust attempted explain what it was doing to try and treat this, and to keep Mr E’s family updated.

54. We acknowledge here what Mrs O has told us about the impact of the Trust’s communication. She has told us how Mr E’s son returned home to America and missed the opportunity to spend time with Mr E in his final days. We acknowledge and accept this would have been extremely upsetting for Mrs O and her family.

55. To an extent, there is conflicting evidence here, and it is difficult for us to reach a balanced decision. Mrs O has suggested the Trust did not communicate with the family about the care Mr E was receiving. The contemporaneous records the Trust kept suggested it did speak with Mr E’s family about the care and treatment it was providing, and his condition.

56. On the balance of probabilities, we think it is likely the Trust did communicate with Mr E’s family in line with GMC guidance. There is evidence to suggest Trust spoke with Mr E’s family about his care and treatment while he was admitted at the Trust. The evidence suggests the Trust attempted to answer the questions Mr E’s family had in relation to his care.

57. It also appears the Trust communicated with Mr E’s family about his condition, his improvement and possible deterioration, throughout his admission. We recognise there may have been a shortcoming here. While it appears the Trust spoke with the family about this, it is not clear the family fully understood the severity of Mr E’s condition, given the actions of Mr E’s son.

58. We have considered the number of conversations the Trust appears to have had, and the content the Trust noted of these discussions. On the balance of probabilities, we think the Trust has acted in line with the GMC guidance. As we have seen no indication of a failing in relation to this issue of the complaint, we will be taking no further action here.

59. We acknowledge Mrs O will likely be disappointed by our decision. We hope it does not add to the distress she has already experienced.

Dignity

60. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we think the Trust has already done enough to put right the impact of these events.

61. Mrs O complains the Trust cared for Mr E with a lack of dignity. She is concerned the Trust left Mr E on a ward bed naked, without any privacy.

62. The NMC Code says nurses must balance the need to act in the best interests of people at all times, with the requirement to respect a person’s right to accept or refuse treatment. It also says nurses should made sure dignity is preserved and needs are recognised and responded to.

63. We can see from the records Mr E was very agitated on the day in question. The records suggest Mr E had taken his clothes and pad off. The records also show he attempted to remove his catheter and cannula. We can also see the Trust did try to manage his agitation via medication and redressed him together with repositioning his cannula and catheter.

64. We understand why Mrs O felt Mr E was not cared for with dignity. We appreciate it would have been distressing for Mrs O to see her father naked in a ward bed. There is evidence to suggest the Trust was attempting to provide care that was in line with the NMC. On the balance of probabilities, we think it is likely the Trust fell short of this at times.

65. Our Principles of Good Administration say organisations should acknowledge mistakes and apologise where appropriate. They should learn lessons from complaints and use these to improve services and performance.

66. In the Trust response, the Trust acknowledged the way Mrs O found Mr E on the ward was not to the high standard of nursing care the nursing staff aspire to achieve. It apologised for this.

67. The Trust also said it had taken steps to ensure something like this does not occur again. It explained it had used the feedback it received and discussed this in its daily huddle and team meetings.

68. These actions appear to be in line with to Our Principles of Good Administration. We can see the Trust acknowledged that it likely got things wrong here, and it apologised for that. It also took steps to try and improve the service it provides.

69. We acknowledge Mrs O and her family experienced a difficult time while Mr E was admitted into the Trust. As explained above, we think it is likely there were some shortcomings in the care the Trust provided to Mr E. We think the Trust has taken steps that are in line with Our Principles to put things right here.

70. For the reasons outlined above we will not consider this complaint further. We thank Mrs O for bringing her complaint to us for consideration.

1. We have carefully considered Mrs O’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We have seen no indication the Trust did anything wrong in the treatment provided to her father, Mr E, during his admission.

2. We think there were likely some shortcomings in the Trust’s communication with the family. Overall, on the balance of probabilities, we do not think we can say there was an indication of a failing here. We also think there are likely some shortcomings in the nursing care provided, which caused a lack of dignity for Mr E and distress for his family. We think the Trust has taken steps to put this right.

3. We acknowledge Mrs O and her family have experienced a very difficult period and extend our condolences for the death of Mr E. We therefore recognise our decision may be disappointing.