Pneumonia 31. Mr L complains SWFT failed to appropriately treat Mr O’s pneumonia. We hope to assure Mr L we find evidence to show the presumed diagnosis of pneumonia, and the treatment given to Mr O for it, was appropriate.
32. On admission to SWFT, Mr O had pleuritic chest pain (a sharp, stabbing pain in the chest that worsens with breathing, coughing or sneezing), shortness of breath and a cough with audible chest crackles. He had an elevated C-reactive protein level (CRP, a marker in the blood indicating infection or inflammation when raised) and his chest X-ray reported increased opacification (an appearance of cloudiness or haziness). Our respiratory adviser confirms these are all findings consistent with pneumonia.
33. Mr O had also recently been seriously unwell, he was immunocompromised due to his advanced cancer and along with his age, these factors all increased his risk of developing infection. Considering the clinical presentation, findings from imaging and blood test results, our respiratory adviser confirms it was reasonable SWFT treated Mr O for a presumed diagnosis of pneumonia.
34. SWFT gave Mr O treatment in the form of the antibiotic tazocin. This was in line with BNF recommendations as an appropriate antibiotic to treat pneumonia infections. Our respiratory adviser explains as a broad-spectrum antibiotic, the choice of tazocin, its duration, and the different routes by which it was given to Mr O were all appropriate and in keeping with the changing clinical picture.
35. We know Mr L specifically complains that SWFT failed to test the fluid or take a chest X-ray following thoracentesis to establish the type of infection, monitor its progression and inform antibiotic treatment. We hope to assure him we find no clinical requirement for either action.
36. Records of the thoracentesis procedure note a ‘dry tap’, meaning no fluid was drained. This is because there was only a 1cm rim of fluid present, which is considered very small. There was no fluid drained to have required testing. Needle testing can be done for the purpose of helping inform the choice of medication treatment. Our respiratory adviser explains that as Mr O was already receiving appropriate antibiotic treatment, there was no clinical need to expose him to this procedure which is not only invasive but could involve potentially harmful complications.
37. Regarding Mr L’s concern of repeat chest X-ray, whilst there is no national guidance on this specifically, our respiratory adviser explains that not repeating chest X-ray after using an ultrasound to guide procedures like this, is standard and good clinical practice. They explain it is commonly set out in local hospital policies, for example Barts Health’s policy says: ‘A post procedure chest radiograph is only needed after a diagnostic aspiration if the operator has concerns regarding complications’.
38. Our respiratory adviser explains there is no requirement for repeat X-ray post-thoracentesis unless a complication was thought to have occurred during the procedure, or if a new baseline X-ray is needed after the removal of a substantial amount of fluid. Neither of these applied in Mr O’s case.
39. Repeat chest X-ray was also not necessitated because the amount of fluid present at that time was so small. An ultrasound taken on 3 November found a 4cm rim of fluid, meaning by the time of thoracentesis on 15 November, findings of a 1cm rim indicated improvement.
40. We very much hope to assure Mr L from the evidence we have considered we do not see any service failure in SWFT’s treatment of Mr O’s presumed pneumonia.
Collapsed lungs 41. Mr L complains SWFT failed to identify or treat Mr O’s collapsed lungs, specifically in failing to take an X-ray following thoracentesis to check the procedure had not caused this damage.
42. We hope to assure Mr L there is no evidence Mr O had collapsed lungs. We think it likely this concern has come from Mr L having misunderstood the medical terminology used by the pathologist in the post-mortem report. The relevant part of the post-mortem reads: ‘Both lungs were globally airless with pan-lobal congestive atelectasis’.
43. Atelectasis is a medical term that refers to a circumstance when the little pockets within the lungs have closed shut. It is a term used to describe a variety of differing circumstances, of differing severities. Whilst it can be used to mean a full collapse of a lung, it can also describe small areas of these pockets in the lung that have closed for example because of mucus impaction, or it can describe small scars within the lung, or areas that are compressed by fluid surrounding the lung – where the lung may not be able to fully expand for various reasons, but on a much more minor scale to that of full collapse.
44. Our respiratory adviser explains the atelectasis described by the pathologist in Mr O’s case refers to an indirect collapse of the pockets due to congestion, most likely the result of his heart failure. This was a known part of Mr O’s clinical picture and was considered as part of his management plan.
45. The imaging, investigations and tests conducted by SWFT during Mr O’s admission did not demonstrate any signs of collapsed lungs in the manner that has been alleged. We can therefore assure Mr L we do not find any evidence to suggest SWFT failed to identify or treat collapsed lungs, as we do not find evidence of collapsed lungs in this regard. We note Mr L’s specific concern here about post-thoracentesis chest X-ray, and we are satisfied we have addressed this in the previous section of our report.
Oncology input and treatment 46. Mr L complains SWFT failed to give Mr O sufficient oncology input or any treatment for his cancer. We hope to assure him the evidence shows Mr O received sufficient input from the acute oncology service as well as direct liaison with the treating consultant oncologist, and appropriate decisions were made regarding Mr O’s cancer treatment.
47. For context, whilst there are some specialist cancer care facilities around the country, in general, patients who are admitted to hospital either for their cancer or with a cancer, are admitted into a general acute hospital. To ensure delivery of appropriate specialist cancer input for those patients, the UK oncology nursing society (UKONS), part of the UK acute oncology society (UKAOS) developed guidance, to provide a framework to ensure all hospitals in England have access to an acute oncology service.
48. Records show the acute oncology service was contacted and provided advice on Mr O’s management, which was followed by the treating team. We are assured the evidence shows Mr O received appropriate input, in line with UKONS/UKAOS guidance.
49. Mr L was not admitted directly because of his cancer, meaning oncology input was not required with any immediacy. We know Mr L is concerned to have seen in the records a note on 8 November requesting ‘URGENT’ oncology review. This urgency was noted due to a pharmacy request for ongoing prescription of abiraterone, the medication treatment Mr O was taking for his prostate cancer.
50. On 8 November, records show the treating team spoke with the acute oncology service. Acute oncology provided immediate input, advising to hold abiraterone for now, and said they would review Mr O the following day. This review went ahead as planned, at which the acute oncology service advised the treating team to continue to withhold abiraterone.
51. Our oncology adviser explains abiraterone is known to increase the risk of worsening fluid retention. The acute oncology service documented that along with his metastatic cancer, Mr O had pleural and pericardial effusions and fluid retention in both legs. The decision to withhold abiraterone was therefore clinically appropriate, taken in consideration of Mr O’s current circumstances, and in consultation with the acute oncology service.
52. Our oncology adviser explains whilst there is no national guidance on this specifically, GMC guidance applies. It advises clinicians:
15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a adequately assess the patient’s conditions, taking account of their history […], their views and values; where necessary, examine the patient b promptly provide or arrange suitable advice, investigations or treatment where necessary c refer a patient to another practitioner when this serves the patient’s needs.
16 In providing clinical care you must: a prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b provide effective treatments based on the best available evidence c take all possible steps to alleviate pain and distress whether or not a cure may be possible d consult colleagues where appropriate […]
53. We are assured by the recorded evidence, that SWFT followed GMC guidance here.
54. On 10 November, Mr O had a CT scan which found new, extensive cancerous lesions in the liver. At the ward round the following day, the treating team documented this finding of new sites of cancer, noting that Mr O already had an oncology appointment scheduled for 15 November. With this appointment scheduled in just a few days’ time, our oncology adviser confirms there was no additional or alternative action required for SWFT to take.
55. The treating team also shared these findings with the treating consultant oncologist who worked outside of SWFT. This consultant spoke with Mr O on 15 November, after which they wrote a clinic letter, confirming they had been made aware of the findings on CT and the decision to withhold abiraterone. This confirms good practice in line with GMC guidance by the treating team. The consultant wrote of their suspicion that Mr O had a secondary cancer, and planned to see him in the outpatient clinic, after his admission.
56. Whilst the consultant oncologist worked outside of SWFT and therefore does not form part of our investigation into the care provided by SWFT, our oncology adviser confirms the decision to review Mr O when better recovered from his current acute admission was entirely appropriate. There was no clinical requirement for additional or any more immediate oncology input from SWFT at that time.
57. We know how concerned Mr L is about his stepfather’s underlying cancer. We hope to assure him the evidence shows appropriate oncology input and treatment decisions were made during Mr O’s admission to SWFT.
Antibiotics 58. Mr L complains SWFT inappropriately stopped Mr O’s antibiotics on 15 November despite his active infections.
59. As we explained earlier in our report, we find evidence to show the early presumed diagnosis of pneumonia and the antibiotic treatment given to Mr O for it, was appropriate. By 15 November, Mr O had received 10 days’ worth of antibiotics. Despite this being the appropriate treatment for a pneumonia infection, after such a lengthy course, Mr O’s CRP was not substantially lowered.
60. Five days earlier, on 10 November, Mr O had a CT scan. Our respiratory adviser explains this did not show any consolidation (an area where the lung is filled with fluid) to suggest there was any residual infection. This means the CT scan did not show a picture of a resolving pneumonia infection. Instead, it showed a very mild left pleural effusion, which our respiratory adviser explains most likely developed because of Mr O’s heart failure.
61. Considering this, as well as the CT scan reporting newly identified metastases, the treating team suspected Mr O’s raised CRP was most likely due to his cancer. Our respiratory adviser says this means from that time on, it was entirely appropriate to no longer treat a pneumonia, as the clinical picture had changed and no longer suggested infection.
62. On 14 November records document there were no clear signs of infection and Mr O had been afebrile (not feverish) for the past 48 hours. These findings aligned with the earlier CT scan report. The consultant documented the plan to stop tazocin, with knowledge of Mr O’s upcoming appointment with oncology and to commence discharge planning. Our respiratory adviser confirms this was appropriate, as by that time, there was no indication of any active infection nor clinical need to continue antibiotics.
63. The consultant’s review on 15 November maintained the previous day’s plan and requested advice from microbiology. This was obtained that afternoon with microbiology specialists also confirming the plan to stop antibiotics. These actions were in line with GMC guidance. We hope this explanation gives Mr L the assurance that there was no indication of any active infection, nor any clinical need for continuing antibiotic provision at the time it was stopped. We do not see any service failure here.
Discharge 64. Mr L complains SWFT unsafely discharged Mr O on 18 November. DoH discharge guidance contains specific criteria that should be met before a patient is sent home safely, from a clinical perspective. The guidance says if the answer to each criteria is ‘no’, then active consideration for discharge must be made. The criteria questions are as follows:
• requiring intensive care unit or high dependency unit care?
• requiring oxygen therapy or non-invasive ventilation?
• requiring intravenous fluids?
• National Early Warning Score [measuring vital signs] greater than 3?
• diminished level of consciousness where recovery is realistic?
• acute functional impairment in excess of home or community care provision?
• last hours of life?
• requiring intravenous medication greater than twice a day (including analgesia)?
• undergone lower limb surgery within 48 hours?
• undergone thorax-abdominal/pelvic surgery with 72 hours?
• within 24 hours of an invasive procedure? (with attendant risk of acute life- threatening deterioration)
65. Mr O did not meet any of the above criteria that would have precluded him from discharge on 18 November. DoH discharge guidance acknowledges that clinical exceptions to the criteria will occur, stating that any such exception must be warranted and justified. Our respiratory adviser does not find any reason for a clinical exception in Mr O’s case. We do not find any evidence to suggest a service failure with the clinical decision to discharge.
66. Mr L has raised various concerns as to why he maintains the discharge was unsafe, specifically that Mr O lived alone and needed assistance, stating he was far too unwell to manage his medications at home, that he was discharged without antibiotics despite having active infections and there was no occupational therapy assessment of his home and mobility. We hope to assure Mr L we find a wealth of recorded evidence showing the discharge planning process was appropriate and considered the relevant factors. We consider each of Mr L’s listed concerns below.
67. Mr L complains his stepfather was discharged without antibiotics despite having active infections. As we explained earlier in our report, antibiotics were appropriately stopped during Mr O’s admission as there was no clinical indication of infection, therefore no clinical need for them to continue. Our respiratory adviser confirms that there remained no clinical indication for them at the point of Mr O’s discharge.
68. We recognise Mr L’s concern that his stepfather lived alone and needed assistance. Records document Mr O lived on his own in a supported living facility, where he received a daily package of care. Mr L told us his stepfather’s carers would attend to him three times a day. The evidence shows Mr O’s home circumstances were known to SWFT and taken account of during its discharge planning process. This included SWFT coordinating with a social worker to re-start the package of care within hours of Mr O’s return home.
69. We understand Mr L felt his stepfather was too unwell to be able to manage his medication at home. The nursing records show there were no communication difficulties and Mr O was able to express his needs. He was asked about discharge, and it is noted that he expressed no concerns about going home. This was reiterated by the social worker who spoke with Mr O about restarting his package of care once home. The evidence assures us his capabilities and wishes were considered, along with knowledge he would receive care visits daily.
70. Mr L raises concern that there was no occupational therapy assessment of his stepfather’s home and mobility. The recorded evidence shows occupational therapy were included in the multidisciplinary team that were involved in Mr O’s discharge planning. This team included nurses, doctors, a social worker, physiotherapy and occupational therapy. A discharge co-coordinator was also involved, and a discharge checklist was completed, which our nursing adviser confirms supports a structured discharge, ensuring that no aspects of the discharge process had been missed.
71. Nursing and physiotherapy records document that Mr O was independent with his mobility and with washing and dressing. It is documented Mr O attended to his own hygiene needs, including emptying his catheter bag. He had no problems with eating and drinking, and records note he was sufficiently independently mobile. Our nursing adviser explains the records do not highlight any need for assistance with daily living tasks, nor mobility needs that would have warranted a home visit.
72. DoH guidance says whether at home or in a community setting, individuals should be discharged to the best place for them to continue recovery if needed in a safe, appropriate and timely way. It says when it becomes apparent that someone may need support from social care services to aid their discharge and recovery, NHS trusts should inform the relevant local authority of this need as early as possible in the person’s hospital stay, to allow local areas to cooperate on the person’s discharge planning. DoH guidance also says the discharge coordinator should ensure that the discharge plan takes account of the person's social and emotional wellbeing, as well as the practicalities of daily living.
73. NMC Standards guidance also applies and says nurses should demonstrate the ability to coordinate and undertake the processes and procedures involved in routine planning and management of safe discharge home or transfer of people between care settings.
74. Our nursing adviser confirms discharge planning in Mr O’s case was in line with DoH and NMC Standards guidance and our respiratory adviser confirms there was no clinical indication Mr O was not medically fit to be discharged on 18 November.
75. We recognise this was a worrying time for Mr L, with his stepfather returning home after his recent hospital admission. We hope to assure him we find the discharge planning and decision to have discharged Mr O appropriate and taken in line with guidance.
UHB
District Nursing visit 76. Mr L complains that UHB District Nurses failed to visit when he and his stepfather’s carers informed them on 19 and 21 November of concerns with his catheter, blood in his urine, and a need for a hospital bed at home.
77. As we explained in our earlier background section, at 5.47pm on 19 November one of Mr O’s carers called UHB’s community adult nursing and therapy team. Records note the carer found only a small amount of urine in the bag and was therefore concerned the catheter wasn’t draining, asking if a UHB nurse could attend to assess. Our nursing adviser says in these circumstances, a phone call in the first instance would be indicated so the urgency of the issue could be assessed. Appropriately, UHB telephoned and spoke with Mr O directly and without delay, at 6.02pm.
78. Records of this call note the UHB nurse spoke with Mr O about his carer’s concern of only a small amount of urine in the bag, and asked Mr O if he was drinking plenty. The UHB nurse noted Mr O said he was not drinking much, noting this could be the reason for the small amount of urine output. It is recorded Mr O had no abdominal pain and did not feel that the catheter was blocked. Our nursing adviser says a lack of abdominal pain is an indicator of no blockage concern. The UHB nurse advised Mr O to increase his fluid intake and to contact the team again if he had any pain or discomfort, or if he felt the catheter was not draining.
79. NMC The Code says nursing staff should: ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’. Our nursing adviser confirms UHB followed NMC The Code here, assessing the circumstance and determining the most likely reason for the carer’s concern was because Mr O was not drinking much. Our nursing adviser confirms the advice UHB gave to Mr O was appropriate. There was no indication of any need for a home visit on this occasion following this appropriate telephone contact with Mr O directly.
80. At around 1pm on 21 November the UHB team received a referral from Mr O’s carers with concern of blood in his catheter and queries over the need for a hospital bed at his home. Just as before, our nursing adviser says a phone call is first indicated to assess the urgency of the issue. Appropriately, a UHB nurse telephoned and spoke with Mr O directly and without delay. It is noted Mr O said he had no problem with his catheter at all, that it was draining well and he raised no issues. The UHB nurse documented raising the matter of the hospital bed with the District Nursing team, to consider assessment.
81. Records then note a UHB nurse then telephoned and spoke with Mr L. It is noted Mr L advised his stepfather had been discharged from hospital with no follow-up, that he was unsure how his stepfather would cope due to reduced mobility, being weak and needing more assistance. Mr L advised that his stepfather had carers attending three times a day. The UHB nurse said they would arrange a visit this week to assess Mr O and recorded that Mr L appeared happy with this plan.
82. NMC Standards guidance says nurses should be able to understand and apply a person-centred approach to nursing care, demonstrating shared assessment, planning, decision making and goal setting when working with people, their families, communities and populations of all ages. Our nursing adviser confirms UHB followed NMC The Code and NMC Standards guidance here.
83. Mr L’s complaint is that District Nurses did not visit Mr O in response to these contacts from his carers. As we have explained, requests for home visits are triaged to consider the urgency of the request. District Nurses are not an emergency service, they have large caseloads and must triage their response times to home visit requests. On both occasions where Mr O’s carers raised concerns, records show the UHB nursing team completed this triage by calling and speaking with Mr O directly and without any delay. This was appropriate, and in line with the NMC guidance we have cited.
84. Our nursing adviser explains that there is no national guidance that sets out the timeframe that should be met for home visits. They explain response times are set locally and are typically within 24 hours and then within seven days.
85. Mr O confirmed on both occasions that he had no concerns with his catheter. The visit was therefore for an assessment of need, following concerns raised by Mr L over his stepfather’s reduced mobility, and the carer’s request to consider a hospital bed. UHB nurses were aware Mr O already had a three-times-a-day package of care in place. The visit would therefore be to assess the environment and consider options to prevent falls and improve independence.
86. Our nursing adviser explains this assessment of need would reasonably fall within the seven-day timeframe. This is the action the UHB nurse took, when confirming with Mr L that they would arrange a visit to assess Mr O that week. We hope to assure Mr L that from the evidence we have seen, we do not find any service failure in the UHB nursing team’s actions on these occasions.
In conclusion 87. We recognise how much these events, and Mr O’s subsequent death, have affected Mr L. We understand how difficult this time was for him, and we know it continues to cause him such upset to this day.
88. We very much hope our decision can provide Mr L assurance about the care his stepfather received, and that our report has fully explained the reasons for our decision.