25. 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 also consider whether it looks like the mistake caused suffering, or affected someone in another way, and whether more needs to be done to address this.
Delay in biopsy sample for testing
26. Mrs H has raised concerns about the Trust failure to send her mother’s biopsy sample for molecular testing, which she says led to delays in cancer treatment.
27. The Trust has accepted there was an error in the referral system which meant the molecular testing was not requested when it should have been. It has apologised to Mrs H for this error.
28. We discussed the importance of molecular testing with our oncologist and whether the delay by the Trust had any lasting or significant impact on Mrs K.
29. Firstly, it is important to note that Mrs K was essentially receiving palliative care, to help try and prolong the quality and quantity of her life.
30. Our oncology adviser explained that because the Trust suspected Mrs K had lung cancer, the biopsy sample needed to be sent for molecular testing to establish a definitive diagnosis. This would enable the Trust to plan the most appropriate treatment plan.
31. Our oncology adviser told us molecular testing is either done as a reflex (all cases are sent) or done following a multidisciplinary team meeting (MDT), where the MDT would request for it to be done, as was the case here.
32. The MDT requested it on 1 November and arranged to re-discuss once the molecular testing was sent back on 13 December 2022. It was at this point the MDT discovered the molecular results were not completed.
33. Mrs K was referred to oncology on 16 December, but the referral was rejected as the molecular results were not available. As such, it appears had the tests been carried out the referral on 16 December would have been actioned. Subsequently, after the Trust acknowledged its error, the molecular testing was carried out and the results became available, and it referred Mrs K on 23 December 2022 (seven days later than she initially should have been). Following the referral the Trust started chemotherapy treatment on 12 January 2023.
34. Two weeks after treatment started Mrs K was admitted to hospital with a spinal cord compression. Our oncologist adviser explained that even if the referral went ahead on 16 December and treatment would have started seven days sooner, on the balance of probabilities the deterioration in Mrs K health would not have been avoided, given treatment usually takes six weeks to start taking an effect.
35. There was clearly a delay in sending the biopsy samples for molecular testing, but it does not appear this had any impact on Mrs K’s health or treatment plan. The Trust has already apologised for its error and taken steps to ensure this does not happened again. As such we are satisfied this put things right in line with the NHS complaint standards, which state:
‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint’.
Discharge 28 December 2022
36. We then looked at Mrs K’s discharge on 28 December.
37. We discussed this with our nursing adviser who explained the Trust correctly completed a discharge check list and made referrals to the district nursing team and the palliative care team. Our nursing adviser also explained from the information available there was no indication the discharge was unsafe.
38. This appears to be in line with NICE guidance on discharge planning for end-of-life care which states the following;
‘The discharge coordinator should work with the hospital and community based multidisciplinary teams and the person receiving care to develop and agree a discharge plan’
‘The named consultant responsible for a person's end of life care should consider referring them to a specialist palliative care team before they are transferred from hospital’.
39. It is also worth noting that the day after the Trust discharged Mrs K, the palliative care team contacted Mrs H and the only concerns raised were regarding Mrs K’s swollen legs. The palliative care team explained a GP was going to make a home visit later that day to go through any concerns she may have. This suggests the referrals were made as outlined in the discharge notes.
40. We have not seen any indications that anything went wrong here, and do not propose to investigate this issue any further.
Pressure sores and risk assessments during hospital admission
41. Mrs H also complains that her mother acquired grade two pressure sores in hospital and has raised concerns that these were not managed nor were appropriate risk assessments carried out.
42. The Trust explained on admission to the emergency assessment unit on 24 January 2023, it completed a pressure ulcer risk assessment on admission. It says Mrs K was identified as having no pressure ulcers but was at risk of developing pressure damage. The plan was to commence her on the primary prevention pathway. This included, regular repositioning, being nursed on a high foam mattress and four hourly skin reviews.
43. The Trust said on 26 January 2023, Mrs K sadly developed pressure damage on the right buttock, and a wound assessment document was commenced, a dressing applied to the area and an airflow mattress requested.
44. Our nursing adviser who explained when Mrs K was admitted to hospital on 24 January 2023, the Trust completed a pressure ulcer risk assessment and was commenced on the prevention care pathway (as stated in paragraph 42). This was in line with NICE guidance, on pressure sore prevention and management.
45. It appears from the recorded documentation that Mrs K likely already had some pressure damage on admission to hospital, as a document from the district nursing team on 16 January said that a grade 1 pressure ulcer had been noted to her right inner buttock.
46. Our nursing adviser confirmed the Trust commenced Mrs K on a pressure damage prevention care pathway. It completed a body map of Mrs K and a Daily SSKIN rare plan was commenced, which recommended four hourly repositioning. It is worth noting due to Mrs K’s spinal cord compression, this could have made regular repositioning very difficult.
47. It is documented in the records on 26 January 2023 that Mrs K had a pressure sore on her right buttock and a dressing was put in place. The Trust also requested a medical photography, submitted a Datix (incident reporting and risk management system) and an air mattress requested. Again, this was in line with NICE guidance on pressure sore prevention and management.
48. Although it does appear the Trust was struggling to reposition Mrs K due to her spinal cord compression, there are no indications of failings in respect to prevention and management of the pressure sores, given the Trust appear to have been managing it as effectively as possible. We recognise this does not take away the distress and upset Mrs H experienced knowing her mother had pressure sores that would have made her suffer increased pain and discomfort.
Covid-19 risk mitigation and management
49. Mrs H said whilst in hospital the Trust moved her mother on to a ward with patients known to have covid-19. She says her mother contracted Covid-19 and believes this was a contributing factor in her death.
50. Mrs H has told us her mother was clinically vulnerable and immunosuppressed.
51. The Trust explained that all patients admitted to hospital are vulnerable to contracting covid-19, Mrs K equally so. it says her comorbidities and recent treatments would raise the risk of her having increased severity of symptoms and complications related to Covid-19.
52. It is documented that the Trust transferred Mrs K from A&E to the surgical decisions unit (SDU), where she was initially nursed in a ‘side room’ before being transferred to ward 26 on 18 February 2023.
53. Covid-19 guidance for people whose immune system means they are at higher risk states:
‘The NHS does not universally require all immunocompromised patients to be isolated inpatient. Instead, the focus is on those who are at higher risk of serious illness from COVID-19, regardless of vaccination status. Enhanced protection measures, such as specific treatments or additional vaccinations, may benefit these individuals. It is essential for healthcare professionals to assess the risk of infection and implement appropriate isolation precautions based on the patient's condition and the risk of transmission’.
54. Our nursing adviser explained due to the success of the covid vaccination programme, it was no longer such an important requirement to isolate patients such as Mrs K, on admission to hospital, even though she would have been categorised as immunocompromised. The priority of a side room would be allocated to a patient showing signs of a transmissible infection.
55. NHS England, National infection prevention and control manual (NIPCM) for England guidance states:
‘The clinical judgement and expertise of the staff involved in a patient’s management and the infection prevention and control team (IPCT) should be sought, particularly for the application of TBPs, e.g. isolation prioritization, when single rooms are in short supply’.
• if single rooms are limited, infectious patients who have conditions that could increase the risk of transmission of infection to other patients, such as, excessive cough should be prioritised for placement in a single room.
• single room prioritisation should be reviewed daily and the clinical judgement and expertise of the staff involved in a patient’s management and the Infection Prevention and Control Team (IPCT) should be sought particularly for the application of TBPs.
56. As such, although, we appreciate Mrs K developed Covid-19 once the Trust moved her onto ward 26, we have seen no indication it acted inappropriately or outside the published guidance at the time.
57. We then looked at whether the Trust acted appropriately once Mrs K developed covid-19 whilst in hospital.
58. The records show the Trust swabbed for covid-19 on 27 February 2023 following a new cough and high temperature. It Is documented in the medical notes that staff then sought to isolate Mrs K in a side room. Other patients were also swabbed to test for covid-19. The Trust also referred Mrs K to both the medical team and the palliative care team for review.
59. Our nursing adviser explained that the Trust monitored Mrs K due to her clinical deterioration as well as her Covid-19 diagnosis. Our nursing adviser explained Mrs K appears to have become very unwell, very quickly. As such, the Trust commenced her on a sub-cutaneous syringe driver (delivers a continuous, steady flow of medication through a thin tube inserted just under the skin) filled with medications that would help manage Mrs K’s symptoms. The Trust also gave Mrs K a ‘bear hugger’ to help warm her up and commenced on oxygen due to her shortness of breath.
60. This was in line with NICE Covid-19 rapid guidance which states the following:
‘Base decisions about escalating treatment within the hospital on the likelihood of a person's recovery. Consider their treatment expectations, goals of care and the likelihood that they will recover to an outcome that is acceptable to them’
61. NMC, the code guidance also states staff should treat people as individuals and uphold their dignity. It appears the Trust did do this in this instance and there is no indication the Trust acted wrongly when managing Mrs K’s symptoms of covid-19.
Administration of oxygen and communication
62. Mrs H has concerns that the Trust failed to administer her mother with oxygen prior to her death.
63. She has said her mother was struggling to breathe hours prior to her death.
64. Our nursing adviser explained the Trust administered oxygen to Mrs K due to her shortness of breath and her respiratory rate being 35, as outlined in the nursing notes. This was in line with NICE guidance on care of dying adults in the last days of life, pharmacological interventions. This is because, it appears the Trust considered pharmacological interventions to best help managed Mrs K’s symptoms.
65. There is no indication from the evidence we have seen that oxygen was required prior to when the Trust administered it.
66. Finally, we looked at the communication with Mrs K and her family (including Mrs H). Communication can sometimes be subjective and as such, we took a holistic approach on communication between the Trust and Mrs K and her family.
67. Our nursing adviser explained it is documented throughout Mrs K’s hospital admission Mrs H was present during discussion with staff regarding her mother’s condition. It also appears the Trust contacted Mrs H on several occasions whilst her mother was an outpatient.
68. It is important to note Mrs K did have capacity and was able to communicate effectively throughout her inpatient stays, implying that she would share any information that she wanted to with her family.
69. From the evidence we have seen, it does appear Mrs K was noted as alert and communicating with staff throughout her stay in hospital. It was noted Mrs K was communicating her ‘needs well’.
70. Although, we appreciate Mrs H feels the communication by the Trust fell short of the standard she would have expected, we have seen nothing to suggest it fell short of NMC, the code guidance on communication which states:
• use terms that people in your care, colleagues and the public can understand, • take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs, • check people’s understanding from time to time to keep misunderstanding or mistakes to a minimum, • be able to communicate clearly and effectively in English.
71. We hope our consideration of Mrs H’s complaint gives her the explanations she is seeking and will help bring her some closure to this traumatic time.
Complaint handling
72. Mrs H has raised several concerns with how the Trust handled her complaint. Specifically, she says there were delays, miscommunication and unsatisfactory responses.
73. Mrs H told us she raised a complaint initially on 15 December 2022 but says the Trust never formally investigated the case. This was despite the Trust giving written assurances on 27 February 2023. She says it was not until 26 January 2024, that the Trust invited her to a local resolution meeting to discuss her concerns and she says the Trust eventually sent an ‘incomplete’ final response in September 2024.
74. The Trust said Mrs H’s initial complaint was received on 7 December 2022, but a ‘Duty of Candour’ (DoC) was identified and initiated and therefore, the investigation and response was via its DoC route rather than its complaint route. Subsequently, this meant the Trust closed the complaint down in February 2023.
75. It said it received a further complaint letter from Mrs H on 9 October 2023 an held a local resolution meeting on 5 February 2024. Notes were written up from the meeting and sent as a response. The complaint was again closed.
76. The Trust then told us Mrs H sent it another complaint letter on 31 May 2024, and it issued a final response on 26 September 2024.
77. The Trust’s complaint policy states: unless agreed otherwise, all complaints must be responded to within six months commencing on the day on which the complaint was opened.
78. From the evidence we have seen, after receiving the initial complaint in December 2022, the Trust contacted Mrs H to provide a response via the telephone. The Trust assured Mrs H that a DoC had been initiated, and an investigation would be undertaken. It sent a DoC letter to Mrs H in January and subsequently closed the complaint on 27 February 2023. It is unclear why the Trust decided to deal with the complaint solely as a DoC matter and subsequently close her complaint.
79. However, it is clear Mrs H still had ongoing concerns as she wrote back to the Trust on 9 October 2023. In her letter she expressed her dissatisfaction at not receiving a written response to her previous complaint. The Trust acknowledged the complaint on 12 October 2023.
80. NHS complaint standards state: an individual should always be informed on what is happening on their case. In this instance it does not appear this was the case, as the Trust had shut Mrs H’s complaint down when she clearly had ongoing concerns.
81. On 7 November 2023 Mrs H sent an email to the Trust advising she had not had an update and was previously told a local resolution meeting would be arranged.
82. The Trust sent a letter to Mrs H on 19 December 2023, confirming the local resolution meeting would be held on 26 January 2024. Later this was rearranged to 5 February 2024. The Trust sent the minutes from the meeting to Mrs H on 5 March 2024.
83. Mrs H wrote to the Trust again on 31 May 2024 asking for the complaint to be reopened. The Trust sent Mrs H an acknowledgement of the letter on 5 June.
84. On 20 September 2024, the Trust updated Mrs H and apologised for the delay in issuing a response. However, on 26 September 2024, a final response was issued, and the complaint was closed.
85. From Mrs H raising her initial response, she did not receive a final response until 21 months later However, following the Trust’s error in not responding to Mrs H’s initial complaint, it did act in line with its guidance of issuing a response on the two other occasions (the local resolution meeting and its final response in September 2024).
86. It is not fully clear what communication was like between the Trust and Mrs H before both the local resolution meeting and issuing of its final response, as unfortunately, the Trust has moved to a new record keeping system. Although, there is evidence to suggest Mrs H had contacted it for updates on more than one occasions. As such, this again appears to fall outside of the NHS complaint standards.
87. Given the issues we have identified with the way the Trust handled Mrs H’s complaint, there is no doubt this caused her additional frustration, upset and distress. Therefore, we have asked the Trust to acknowledge service failures in complaint handling and apologise for the impact this has caused, and it has agreed to do so.
88. Furthermore, the Trust has recently amended its approach to the way it handles complaints. It has amended is complaints policy which has been approved by its legal team. It has also amended its approach to align with the NHS complaint standards. Considering this and the Trust writing to Mrs H, we are satisfied there is nothing further we can achieve on this matter, and we are satisfied this put things right in line with NHS complaint standards.