Recording weight
24. Miss H complains the Trust did not correctly record Mr H’s weight. She says this caused her concern as she knows weight can affect medication.
25. The Trust explained that nursing staff have alternative ways of estimating weight if a patient is unable to be physically weighed. For example, a nurse can use a patient’s arm circumference as a guidance, or to ask the patient their weight.
26. The Nutrition guidance says all hospital patients on admission should be screened for malnutrition and the risk of malnutrition. One way to do this is by using the MUST tool. One of the steps of MUST is to measure a patient’s height and weight to calculate BMI (body mass index). The MUST guidance provides alternative methods in calculating a BMI (including weight), one way is measuring the mid upper arm circumference.
27. The notes show the Trust recorded two estimated weights. The Trust first recorded Mr H’s weight approximately 19 hours after the Trust admitted Mr H. The next was taken around nine hours later. Both records estimated Mr H’s weight as 65kg.
28. We know from the records that Mr H was not walking and was being nursed in bed by one or two members of staff. We acknowledge this would have made physically weighing Mr H more difficult. It may have been the case that the Trust did measure Mr H’s arm circumference, as it explained in its response to Miss H’s complaint, to estimate his weight. The notes, however, do not say how it estimated Mr H’s weight.
29. The Trust’s actions in screening Mr H on admission to hospital is in line with the Nutrition guidance. This is in the context of gathering information about Mr H’s height and weight. The lack of explanation about how the Trust estimated Mr H’s weight means we cannot be reassured that it estimated this correctly, or that it calculated his BMI correctly.
30. We therefore think there is an indication of a failing here, as the Trust does not appear to have estimated Mr H’s weight in line with the MUST guidance. Miss H explained she was concerned as she knows weight can affect medication.
31. Our physician adviser explained some medications are dosed or adjusted according to a patient’s body weight. Apixaban is one such medication. Apixaban is a type of medication which helps to prevent blood clots.
32. Mr H had been taking apixaban since 2016 after having a stroke. However, Mr H did not receive apixaban during his admission in hospital, nor did he receive any other medication which was reliant on his weight. We are therefore satisfied there was no clinical impact for Mr H caused by how the Trust estimated his weight. We do understand this caused Miss H worry and concern.
33. The NHS Complaint Standards says staff should give meaningful and sincere apologies and explanations that openly reflect on the people concerned.
34. In its response to Miss H’s complaint, the Trust apologised for the impact Mr H’s experience in hospital had on her. We think the Trust’s response is in line with the NHS Complaint Standards. We therefore think the Trust has done enough to put things right here.
35. We understand the worry Miss H has had over this. We hope our explanations here have provided Miss H with some reassurance that even though the Trust estimated Mr H’s weight, this had no effect on his clinical care or outcome.
DNACPR
36. Miss H complains the Trust incorrectly said it had discussed a DNACPR with Mr H and that he had consented to this order. Miss H says the reasons for the Trust putting in place a DNACPR were also incorrect.
37. The Resus guidance outlines the reasons for considering a DNACPR order. This includes where CPR offers no realistic prospect of success.
38. The Trust’s decision not to resuscitate Mr H was due to his frailty and residual disability from a previous stroke. The Trust noted Mr H had a speech impairment, right sided weakness and limb deformity following the stroke. Mr H also required assistance with all activities of daily living (ADL’s) and he had poor mobility. ADLs are the essential self-care tasks required to maintain an individual’s health and independence such as eating, bathing, dressing, and mobility.
39. The Trust also noted that in the unlikely event that they were able to restart Mr H’s heart, he would likely have a poorer quality of life, particularly given he already required assistance with his ADLs and had a speech impairment.
40. Our physician adviser says the reasons for putting a DNACPR in place is in line with the Resus guidance. We have seen no indication of a failing here. The Trust judged that attempting CPR would likely be futile due to Mr H’s frailty. We acknowledge this will be difficult for Miss H, but we have seen nothing to suggest the Trust were wrong to consider CPR would be futile for Mr H.
41. The Resus guidance says there must be a presumption in favour of explaining the need and basis for A DNACPR decision to a patient, or those close to a patient who lack capacity. It is not necessary to obtain the consent of a patient, or of those close to a patient, to a decision not to attempt CPR that has no realistic prospect of success.
42. The records note the Trust considered a DNACPR early in Mr H’s admission during a consultant review. The note of this review state that the consultant discussed CPR with Mr H and ‘he could not retain the conversation. Lacks capacity at this moment in time [regarding] this discussion’. The Trust planned to discuss this with Mr H’s next of kin.
43. Our physician adviser says this note by the consultant shows that the Trust had attempted to discuss DNACPR with Mr H. However, they judged him not to have capacity for this discussion.
44. There is a further note in the records around one hour and 30 minutes later. This note outlines a discussion that took place between a doctor and Miss H as planned. It says the Trust discussed the reasons why it had put a DNACPR in place. It explained that it would be actively treating Mr H for his infection as well as investigating any other issues. The note says Miss H understood.
45. We understand Miss H has a different version of events. She says when she spoke with her father, Mr H said he did not have any discussions regarding resuscitation with a doctor.
46. The evidence in the medical records conflicts with what Miss H says happened. The medical records note that the Trust did discuss the DNACPR with Mr H, and also Miss H afterwards.
47. We acknowledge Miss H says she spoke to her father, and he told her that he had not discussed resuscitation with the doctor. We note here that when the Trust said it had spoken to Mr H, he had been unable to retain the conversation. We therefore think it is possible that the Trust did have that conversation with Mr H, but that as noted, he had not been able to retain it, so had not been able to inform Miss H about this.
48. Having balanced the evidence available, we think it is likely the Trust did speak to Mr H about resuscitation. The Trust’s actions here appear to be in line with the Resus guidance.
49. We note that the guidance says it is not necessary to obtain the consent of the patient, but that they should speak to the patient about the decision. We therefore think the Trust did not need to obtain Mr H’s consent, but it did speak to both him and Miss H about the decision. We have seen no indication anything has gone wrong here.
50. We acknowledge how distressing it would have been for Miss H to have a discussion about CPR with the Trust.
51. Considering the evidence we have, there appear to be no indications of failings in the Trust’s actions here.
Administration of medicine and pain relief
52. Miss H complains the Trust did not provide Mr H with any medication or pain relief when she was with her father in hospital on a day she visited him.
53. The Trust said it did provide Mr H was with medication, including antibiotics and pain relief during this time in hospital. It said pain relief included morphine on an as needed basis if the paracetamol (prescribed on a regular basis) was insufficient to relieve the pain.
54. The Code says nurses must provide medicines or treatment if you have enough knowledge of that person’s health and it serves their needs. It also says to make sure that the care or treatment you supply, dispense or administer for each person is compatible with other care they are receiving. The Code says nurses must keep clear and accurate records relevant to their practice.
55. We have looked at the medication chart for the specific day Miss H visited her father at hospital. The medication chart shows that the Trust prescribed and administered antibiotics such as flucloxacillin, co-amoxiclav, clarithromycin, on the day. This appears to be in line with the Code, as the nurses had given the medication as prescribed.
56. We can see paracetamol and morphine are listed on the prescription chart for pain relief. The records indicate the Trust prescribed paracetamol to be given four times a day. The records reflect this was given on the day in question. Morphine was listed in the medication chart as PRN (when required) and was not a regular dose. The records show the Trust did not administer morphine.
57. We can see the Trust first administered paracetamol at 6.12am. The notes show the Trust first assessed Mr H’s pain score at 10.15am on the day where he scored a four (out of ten). A score of four indicates moderate pain.
58. When the Trust next recorded Mr H’s pain score at 12.17pm, his pain score was zero. The Trust administered paracetamol again at 12.19pm. His pain score remained at zero when the Trust recorded this at different points later in the day. The Trust also administered pain relief regularly later through the day.
59. Miss H said her father was in agony and he ended up dying a painful death. We acknowledge this would have been distressing for Miss H to witness.
60. There is a delay of approximately two hours from when the Trust recorded Mr H’s pain score as four, to when he received his next pain relief medication.
61. Our nursing adviser explains that a nurse should be able to assess what a pain score of four means to the patient. For example, a patient may score four but could decide to decline pain medication, or a patient could score one and request pain medication. A nurse has to be satisfied that whatever has been prescribed meets the patient’s needs, as well as to give the patient an informed choice of what is available for pain relief.
62. When the Trust assessed Mr H’s pain score as four at 10.15am, our nursing adviser said the Trust could have administered pain relief. The Trust could have administered paracetamol as the previous dose was approximately four hours before (it can be administered between four and six hours).
63. They also said the Trust could have administered morphine. However, the nurse’s assessment of the patient’s pain would have helped decide which pain relief, morphine or paracetamol, would be more suitable.
64. There is nothing in the records to say whether a more detailed assessment of Mr H’s pain took place when he scored four. This also makes it difficult for to us know the type of pain Mr H was experiencing at this time, and whether the Trust should have given him pain relief.
65. There is some confusion in the records however. At 9.08am, approximately an hour before the pain score of four, the doctor reviewed Mr H as per the daily ward round. Our nursing adviser says during this ward round, the doctor would assess how the patient was feeling. For example, if the patient is in pain or if they are alert. There is no note from the ward round about whether Mr H was feeling pain at that time.
66. The nursing note recorded at 10.33am, approximately 15 minutes after the pain score of four, states ‘pain score 0/10’. This brings into question whether there is an error in record keeping.
67. Our nursing adviser explains this would be unusual for a patient to report pain. To go from no pain, to then report moderate pain and a score of four, and then to score zero for the rest of the day without any changed scores in between. For example, it may go from a two to a four, down to a two and then down to a zero. Furthermore, they say due to the records not noting any other pain around this time, it is possible the score of four could be an error. However, we cannot be certain.
68. The records do show the Trust administered pain relief. However, we do not know whether a pain score of four required pain relief. This is because we do not know whether an assessment was done of Mr H’s pain, aside from the pain score. This is not in line with the Code as it does not show knowledge of Mr H’s needs. There are indications of failings here.
69. Miss H says she has been deeply affected by the actions of the Trust. She says watching her father die in pain was a massive shock and trauma to her, and her mental health has significantly worsened. Miss H says she has been diagnosed with several mental health conditions due to what happened and feels guilty for leaving her father in the care of Trust and not being able to help him. We acknowledge how difficult this must be for Miss H.
70. From the records, there is only one entry for when Mr H’s pain score was elevated. For the rest of the day in question, he reported his pain score to be zero. The records also show the Trust did administer pain relief.
71. As explained earlier, we do not know whether a pain score of four required pain relief. This is because we do not know whether the Trust carried out an assessment of Mr H and whether he requested pain relief, or the assessment deemed this was appropriate.
72. We do not discount what Miss H has said. We believe her when she said her father was in pain and we understand it would have been distressing for her to witness this.
73. There are conflicting accounts here of what happened. This is because the evidence we have from the Trust says Mr H was not in pain for most of the day, apart from one instance. The evidence from Miss H says Mr H was in agony and he ended up dying a painful death.
74. In this case, we have not been able to reach a view on whether Mr H was in pain, or how long any pain was experienced for. It is regrettable that we are unable to say whether what happened here. We understand this will be distressing for Miss H.
75. The NHS Complaint Standards say organisations should identify suitable and appropriate ways to put things right for people who raise a complaint. It also says organisation should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
76. The Trust apologised for the distress Miss H experienced by seeing her father in pain. The Trust recognised that there were things which the Trust needed to learn following Mr H’s care. It therefore requested a review Mr H’s death by a medical examiner and, separately, by the speciality he was cared by. The Trust explained that both reviews did not raise any concerns about Mr H’s care and treatment.
77. We understand the above may not have provided reassurance to Miss H, especially as she feels very strongly about the lack of care provided to her father. For the indication of a failing we have seen, we recognise the distress caused to Mr H by seeing her father in pain.
78. We are unable to say the other parts of Miss H’s impact claimed (that he died in pain, which caused her a significant worsening of her mental health) can be linked to this. This is because we have only identified once instance of where the Trust recorded Mr H in pain, and the delay in administering pain relief.
79. We want to emphasise that we do not discount what Miss H said happened. The conflicting evidence here has made our decision difficult. We recognise Miss H says her father was in pain for a long time and the Trust had not administered any pain relief. We have identified the Trust did administer pain relief, aside from the one occasion where there was a delay.
80. On balance, we think the Trust’s actions here are in line with the NHS Complaint Standards. It has apologised for the impact caused to Miss H, as well as having initiated a review into her father’s care to provide reassurance around his care and treatment.
81. We appreciate our decision here may cause further distress to Miss H and we are sorry we have not been able to reach the outcome hoped for.
Fluids
82. Miss H also complains the Trust did not provide Mr H with any fluids when she was with her father in hospital on a day she visited him.
83. The IV fluids guidance says healthcare professionals should prescribe and administer IV fluids, and assess and monitor patients receiving IV fluids. Routine maintenance fluids are provided to patients who are unable to stay adequately hydrated through normal oral intake. For an average male, the IV fluids guidance says to administer two litres of fluid per 24 hours.
84. The IV fluids guidance also outlines the circumstances for when a patient may need fluid resuscitation. This includes when a patient has a heart rate of more than 90 beats per minute, and a National Early Warning Score (NEWS – indicates when a patient is acutely unwell) of 5 or more.
85. Fluid resuscitation is when fluids are rapidly administered to a patient tope restore blood volume and improve circulation. If fluid resuscitation is required, 500mls of fluids should be given over 15 minutes. It also says to reassess the patient and to provide regular monitoring.
86. Following the Trust’s initial triage of Mr H in A&E and review by a doctor, Mr H’s ongoing management plan included administering intravenous (IV) fluids. Our physician adviser explained the Trust would have prescribed these fluids as routine maintenance fluids.
87. In the medication chart, we can only see one record of a prescription of fluids. This record shows the Trust prescribed Mr H two bags of IV fluids on one day. The Trust administered one litre at 6.12am and another litre at 2.41pm.
88. A doctor reviewed Mr H at 6.18pm and noted that his bag of fluid was still more than half full. The doctor increased the rate of fluid (existing 500ml of fluids left in the bag) in view of Mr H’s low blood pressure and dehydration. Mr H’s NEWS score was also six at this time.
89. The Trust’s actions here appear to be in line with the IV fluids guidance. It initially prescribed IV fluids for routine maintenance (two litres per 24 hours). However, when the Trust noticed that Mr H had a low blood pressure, it moved to fluid resuscitation. As outlined above, the Trust sped up the rate of existing fluid that Mr H had.
90. There is nothing in the records to say whether the Trust reassessed Mr H after administering fluids for resuscitation. This does not appear to be in line with the IV fluids guidance. The records after Miss H visited her father in hospital support what Miss H has told us, that the Trust did not administer further fluids after the previous fluids had finished
91. On balance, considering the lack of assessment of Mr H after it had started fluid resuscitation, we think this is significant enough to say there is an indication of a failing here.
92. Miss H says her father developed pneumonia in hospital. She says as a result of the Trust not treating this, it led to Mr Sheriff going into septic shock and he died. She believes if the Trust had treated Mr H correctly, her father would not have died as early as he did.
93. The records indicate Mr H had a history of having a weakened heart. Mr H underwent an echocardiogram in 2016 for which the results indicated moderate heart failure. Our physician adviser said this is also likely to have worsened over the preceding six years.
94. Our physician adviser explained in these circumstances, doctors are less keen to prescribe aggressive IV fluid therapy. They said this can sometimes lead to fluid overload in the lungs. They said the doctors may have been hesitant to prescribe IV fluids because of this, however we note the records do not mention this.
95. Without a record of the Trust’s assessment of Mr H following fluid resuscitation, we do know why the Trust did not continue to administer IV fluids. Our physician adviser said on the whole, the Trust should have continued to prescribe IV fluids to Mr H over the night into the next day. However, they said the lack of IV fluids was not a cause or a significant contribution to Mr H’s deterioration and death.
96. Miss H says she has been deeply affected by the actions of the Trust. We do not underestimate how distressing this time must have been for her. We also recognise that our explanations here regarding the lack of assessment of Mr H, and how we do not know why the Trust did not continue to prescribe IV fluids creates uncertainty. Our physician adviser has explained what they think may have happened, but we appreciate this may not provide reassurance to Miss H.
97. The NHS Complaint Standards says staff should give meaningful and sincere apologies and explanations that openly reflect on the people concerned.
98. In the Trust’s response to Miss H’s complaint, the Trust were unable to say why it had not prescribed further fluids for Mr H. The Trust apologised for the impact Mr H’s experience in hospital had on Miss H and how its actions had fallen below the standard it expects. We think this apology is in line with the NHS Complaint Standards.
99. We have seen an indication of a failing in the Trust not providing sufficient fluids to Mr H. We do not think this had an impact on him, but we acknowledge how distressing this was for Miss H, and we understand why she was so worried about the impact on Mr H. We are satisfied the Trust actions here are enough to put things right.
Dignity
100. Miss H complains the Trust left Mr H to die with no dignity. She has told us the Trust had removed Mr H’s pad prior to his death, leaving him naked below the waist.
101. The Code says nurses must respect a person’s right to privacy in all aspects of their care.
102. We cannot see in the notes any reason recorded as to why Mr H was not wearing a pad, or had his pad removed. We accept what Miss H has told us here, that Mr H did not have a pad in place. The notes also do not indicate whether Mr H was naked at this time, however we consider if Mr H was naked from the waist down, that this is related to Mr H not having a pad in place.
103. There are indications of failings here as the Trust does not appear to have acted in line with the Code regarding the removal of the pad.
104. Miss H says she has been deeply affected by the actions of the Trust. We understand how distressing and upsetting it would have been to see her father with a lack of privacy and dignity.
105. The NHS Complaint Standards says staff should give meaningful and sincere apologies and explanations that openly reflect on the people concerned.
106. The Trust apologised that Mr H’s pad was not in place and recognised that this would not have been dignified for him. We think the Trust’s apology here is in line with our NHS Complaint Standards.
Complaint handling
107. Miss H complains the Trust took a very long time to investigate her complaint, and that it did not keep her updated with the progress of her complaint.
108. The Regulations says an organisation should provide a response to a complaint within six months of receiving it. It can take longer to provide a response if it agrees this with the complainant, explains the reasons why it will take longer, and to send the response as soon as it can. The NHS Complaint Standards say organisations should provide regular updates as agreed with the parties involved to keep them informed and involved.
109. Miss H made her complaint to the Trust over the phone in July 2022. The Trust sent over the relevant consent forms for Miss H to complete and send back. It acknowledged her complaint on at the beginning of September. A couple of days later, the Trust contacted Miss H to discuss about arranging a complaints meeting. Miss H sent the Trust the points she wanted to discuss during this meeting.
110. Miss H sent the Trust numerous emails asking for an update on her complaint and the meeting. For the most part, the Trust did not respond to Miss H’s requests although it did on a couple of occasions. The meeting did not take place until late-August 2023, almost a year after Miss H had first made the complaint.
111. Following the complaints meeting in August, Miss H was waiting to receive an audio and written response. She did not receive this until the beginning of February 2024. The written response, however, did not cover all the points that were discussed during the meeting.
112. Miss H contacted the Trust several times without a response. Miss H contacted us and we also contacted the Trust as she had not received a response.
113. In late-May, the Trust responded to Miss H to apologise for the delays in her complaint. It advised her that she would receive a written response within 65 working days, or it would update her if it would take longer. Miss H contacted the Trust several times for an update over the next couple of months but did not receive a response.
114. The Trust contacted Miss H in mid-September to apologise for the lack of communication and delays. It advised Miss H it was waiting for further comments from the relevant departments, and that it would update her weekly.
115. Miss H contacted the Trust later in September and again in October for an update on her complaint, however she received no response.
116. In mid-October, the Trust emailed Miss H with a list of dates it had available for a second complaints meeting. This meeting then took place around a month later. Miss H received an audio recording of the meeting a couple of days after. Miss H received a written response from the meeting in mid-January 2025.
117. We understand it can take some time for an organisation to arrange a complaint meeting due to the busy schedules of different members of staff and clinicians. From when the Trust acknowledged Miss H’s complaint to when the first meeting happened, this took approximately 11 months. It then also took the Trust around five and a half months to provide a written response following the meeting.
118. The Trust’s actions here are significantly over six months. There is no record of the Trust advising Miss H that it would take longer, or even agreeing a timescale for when it would provide a response. This does not appear to be in line with the Regulations.
119. The Trust also did not provide consistent updates to Miss H when she contacted it for updates. It even did not respond to her on multiple occasions. This does not appear to be in line with the NHS Complaint Standards.
120. When the Trust contacted Miss H in late-May, it advised her of the timescales to provide a written response (65 working days). This would have meant a written response was due by late-August. Miss H did not receive a response from the Trust when she contacted it for updates. The Trust’s actions here do not appear to be in line with Regulations nor the NHS Complaint Standards. The Trust did not update Miss H to explain it would take longer to provide a response, and it did not keep her updated.
121. The Trust advised it would update Miss H weekly, however this also did not happen. This does not appear to be in line with the NHS Complaint Standards. The Trust arranged the second complaint meeting relatively quickly, and it issued its written response within two months of the meeting.
122. Overall, the Trust’s actions here do not appear to be in line with the Regulations and the NHS Complaint Standards. It did not responded to her complaint within the timeframe and did not meet its timeframe when it set one. It also did not provide Miss H with regular updates. There are indications of failings here.
123. Miss H also complains the Trust did not provide a complete written summary after the first local resolution meeting in late-August 2023.
124. The NHS Complaint Standards says organisations should give a clear, balanced account of what happened.
125. As explained previously, prior to the meeting taking place, Miss H emailed the Trust a list of concerns which she wanted to discuss in the meeting. The list Miss H provided was comprehensive.
126. In the Trust’s written response following the first meeting, it summarised the apologies it provided during the meeting for two specific complaint points. It also provided general apologies regarding the experience Miss H had with the Trust.
127. We understand the Trust would not provide a verbatim account of what happened in the meeting. However, we would expect it to provide a summary of its explanations and the discussions it had for the points Miss H raised. The Trust was able to do this in its later response in January 2025, following the second complaint meeting. It is unclear why it was unable to do this after the first meeting.
128. The Trust’s actions here do not appear to be in line with the NHS Complaint Standards. It did not provide Miss H with a written response which contained a clear account of what happened during the meeting, and the points it discussed. There is an indication of a failing here.
129. We have seen indications of failings the Trust’s handling of Miss H’s complaint. This includes in the time it took the Trust to respond to Miss H’s complaint, the lack of updates provided, and the incomplete written summary after the first complaint meeting.
130. Miss H said the poor handling of her complaint over years has only exacerbated her grief and trauma of her father’s death.
131. Going through the complaints process can be a stressful experience, especially when the complaint is concerned about the death of a loved one. It is understandable the prolonged complaints process for Miss H in this case, as well as the lack of updates and lack of clear explanations, exacerbated Miss H’s grief.
132. The NHS Complaint Standards say organisations should explain why things went wrong and identify suitable ways to put things right. Organisations should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
133. In the Trust’s letter in May 2024, it acknowledged the difficulties Miss H had faced in raising a complaint with the Trust and the distress it caused her. It reviewed what happened in Miss H’s case and explained why the failings had occurred in its handling of her complaint.
134. The Trust acknowledged that its communication with Miss H was inadequate. It also acknowledged that the delay in providing the audio and written response from the first complaint meeting was unacceptable.
135. This letter has identified several aspects of its complaint handling that it needed to improve. For example:
• implementing a process to track emails to cases to ensure communication is not lost • reiterating the importance of thoroughly checking email addresses before sending information • identifying and implementing a more secure and quicker method for providing audio copies of a meeting • developing training for its complaints staff to outline clear standards for communication with complainants and how to offer support to complainants.
136. The Trust apologised profusely for the impact its actions had on Miss H and the inconvenience caused to her.
137. We have been working closely with the Trust’s complaints department in the last couple of years, and we have seen a marked improvements in its handling of complaints. Particularly the time taken to respond to complaints, when it is usually responding within six months as outlined in the Regulations.
138. We have also seen improvements in communication with complainants and conducting more detailed and thorough investigations. This is reflected in the quality of its written responses to complainants. Based on what the Trust has explained it has done in its May 2024 letter, we think this is in line with the NHS Complaint Standards.
139. We acknowledge how Miss H has told us how the complaints process exacerbated the grief she was experiencing. In terms of the Trust recognising the impact its complaint handling on Miss H, we think the Trust could do more. We considered whether the Trust should pay Miss H a financial remedy in recognition of the emotional impact caused to her.
140. We think a payment of £800 is enough to put enough things right here, to recognise the impact the Trust’s actions had on Miss H. The Trust has agreed to make this payment to resolve the complaint. We will ask the Trust to make this payment within four weeks of the date of this statement.