The Trust failed to communicate Mr M’s true prognosis
28. Mrs M says clinicians suspected Mr M suffered pulmonary embolism. Mrs M says the Trust reassured her this was treatable and as such, the expectation was set that Mr M would recover entirely for this. Mrs M says the family did not expect Mr M to die.
29. Medical records detail the Trust suspected Mr M suffered a pulmonary embolism (blood clot which block a blood vessel in the lungs) on a background of oesophageal cancer with liver metastases (stage 4 oesophageal (food pipe) cancer).
30. Based on medical records, when Mr M arrived at the Trust, he was unwell with a NEWS of 7.
31. Medical records show, by the time Mr M was seen on the post-take ward round (the first review by a consultant on admission) his observations were improving with a better blood pressure and heart rate. Over the course of the day, medical records show Mr M ‘s NEWS observations improved and subsequently his score improved.
32. According to the nursing record, Mr M had been settled. He was noted to be unwell at 9.55pm with shortness of breath. The medical registrar was called. When the nurse returned after calling the registrar Mr M had sadly died.
33. NICE guidance explains NEWS (National Early Warning Score) is a tool which improves the detection of clinical deterioration in adult patients. NEWS scores the physiological measurements that are routinely recorded at the patient's bedside. Its purpose is to identify acutely ill patients, including those with sepsis, in hospitals in England. The NEWS2 scoring system measures 6 physiological parameters: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new-onset confusion and temperature.
34. Our clinical adviser reviewed the medical records and confirmed Mr M’s improved observation in heart rate and blood pressure may have offered clinicals room for optimism that Mr M would continue to improve. They explained the predictability of deterioration and death in any circumstance would depend on response to treatment and the underlying condition.
35. Our adviser also informed us it is not expected within clinical practice that a patient with cancer and a pulmonary embolism deteriorates so acutely, this is because there is an expectation for the patient to respond to treatment. Equally, the adviser accepts it is possible for a patient to deteriorate despite responding to treatment.
36. The British Thoracic Society (BTS) states pulmonary embolism severity index (PESI) can be used to identify patients at higher and lower risk of death. Using PESI model and based on Mr M’s observations and cancer diagnosis, as detailed in the medical records, the prediction is that between 4-11.4% chance of dying within 30 days. As such, the model suggests for patients with active cancer there was a small but significant chance of dying within a month.
37. NHS England details for stage 4 oesophageal cancer the survival is estimated to be 5% in 4 years, which means 95% will of patients will sadly die within 4 years. However, out of those 95% how many will die in a shorter period is difficult to predict.
38. Our adviser confirmed there is no useful prediction model for the combination of pulmonary embolism on a background of oesophageal cancer with liver metastases. Our adviser confirmed the survival can be hours, days or months but would be unlikely to be years.
39. Based on the observations recorded in the medical records, at the time of care, and independent clinical advice we are of the view most probable than not Mr M had a pulmonary embolism.
40. We are pleased to see the Trust also considered pulmonary embolism as a working diagnosis.
41. Based on the PESI score we can see Mr M had a small chance of dying within a month. Based on medical records we can see Mr M was initially responding to treatment and his vital signs improved. As such, we are of the view the Trust had an expectation Mr M was responding well to treatment and would survive longer than he did.
42. Mrs M told us, during the local complaints process, the doctor looking after Mr M recognised they put Mr M’s ‘chances of surviving the night at 50/50 to 60/40’. She also told us, at the time treatment, the Trust advised her Mr M ‘s prognosis was good and her husband would be discharged in 48 hours. Mrs M explains it is her view clinicians did not explain clearly Mr M’s prognosis based on his diagnosis and she felt reassured her husband would recover.
43. Based on independent clinical advice and information from the British Thoracic Society, we can see it is difficult to predict with acuity the risk of dying.
44. We also recognise the Trust and by extension Mrs M felt encouraged when Mr M was stable and showed a slight improvement.
45. Sadly, Mr M unexpectedly deteriorated rapidly and died.
46. We recognise Mrs M would have liked to be by her husband’s side when he died. We can see this was very important for her and she sought reassurance from clinicians in respect to prognosis.
47. GMC’s Good medical practice sets out the principles, values, and standards of professional behaviour expected of all doctors. It states clinicians ‘must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.’
48. Based on PESI tool and medical records we can see the Trust felt encouraged by Mr M’s slight improvement.
49. Based on GMC Good medical practice guidance we can see clinicians must be sensitive and responsive in giving information.
50. Based on evidence we have seen, we are of the view, the Trust provided details on Mr M’s prognosis based on the clinical picture at the time and we are of the view this was in line with GMC Good medical practice guidance. Based on clinical records, it appears to have been very little opportunity to inform the family between Mr M being settled, his acute deterioration and then his death. As such, we do not uphold this part of the complaint.
Sepsis consideration and fluid chart
51. Mrs Ms explains according to medical records the sepsis bundle started at 7am although the Trust admitted her husband in the emergency department a few minutes before 8am. Mrs M also explains elsewhere in the clinical records it is recorded the sepsis bundle started at 8am. Furthermore, she explains the first observations in the emergency department should have flagged potential sepsis as her husband had raised heart rate and had chemotherapy in last seven days.
52. Mrs Ms says the Trust admitted her husband with unknown sepsis and the Trust have admitted it did not fully implement its sepsis care bundle, including failing to swab Mr M’s open pressure sores. Mrs Ms also says the Trust did not obtain a urine sample did not notice her husband did not pass any urine for the duration of his admission.
53. Based on medical records, we can see, Mr M presented with right-sided chest pain radiating (spreading) to the abdomen, low oxygen level and shortness of breath.
54. Medical records show, on examination his heart rate was fast and he had crackles and reduced breath sounds on the right side of his chest, with right upper abdominal discomfort and an ulcer on his left heel.
55. Based on medical records, the Trust carried out a series of tests to gain a better picture of Mr M’s clinical picture. The chest X-ray showed fluid at the base of the right lung. His blood showed raised neutrophils (a subset of white blood cells which rise with infection and inflammation), CRP (c-reactive protein is a blood test that indicates inflammation, often due to infection) and raised D-dimers (D-dimers are proteins that go up when people have blood clots as well as in other conditions).
56. Mr M was treated during his hospital admission with intravenous fluids, intravenous antibiotics, intravenous painkillers and blood thinning medication.
57. NICE’s ‘Pulmonary embolism’ is important for the consideration of this complaint as it relates to the management and diagnosis of pulmonary embolism and Mr M was treated for pulmonary embolism.
58. The above guidance states active cancer is a major risk factor for pulmonary embolism and it highlights the importance of the D-dimer test and provides guidance in respect to anticoagulant treatment.
59. Our clinical adviser reviewed the tests and clinical observations noted in the clinical records and informed there was sufficient evidence in the clinical records to suspect either pneumonia or pulmonary embolism. Our clinical adviser informed us Mr M was treated for both of these conditions with suitable medication. Our clinical adviser confirmed Mr M’s clinical picture was more consistent with pulmonary embolism than sepsis.
60. Based on independent clinical advice and considering NICE’s ‘Pulmonary embolism’ indicates pneumonia can be a differential diagnosis, we reviewed NICE’s ‘Scenario: Community-acquired pneumonia’.
61. We would like to reassure Mrs M that during this investigation we also reviewed the NICE [NG51] in respect to identifying, diagnosing and treating sepsis. NICE [NG51] states if sepsis is suspected then clinician should prescribe a broad-spectrum antibiotic (an antibiotic given to a person before a specific microorganism or source of the potential infection is known) until the source of infection is confirmed or microbiological results are available.
62. We note medical records details the Trust prescribed antibiotic for Mr M. Furthermore, we note the Trust took blood samples and the test results did not indicate a specific microorganism (source of infection).
63. We recognise Mrs M is concerned about record keeping, specifically concerning the sepsis bundle and the NEWS score. We would like to reassure Mrs M, in January 2024, NICE updated the recommendations in respect to managing sepsis in hospital to incorporate use of NEWS2. As such, organisations had to incorporate the new management system in their day-to-day work.
64. Mrs M says the Trust did not record when Mr M went to the toilet, or when he drank water. She feels this shows Mr M was not urinating or drinking water, which Mrs M believes is a red flag and suggests Mr M was more unwell than the Trust thought. Likewise with the care plan and treatment of Mr M.
65. Based on medical records we can see there is no record of fluid input or output. Based on clinical records we can also see Mr M did not require a catheter and did not have a catheter at the time of care.
66. We considered if there was a medical necessity to record fluid input or output.
67. We can see based on blood biochemistry (blood tests) Mr M had normal kidney function.
68. Our clinical adviser reviewed the medical records and advised there was no clinical urgency to monitor urine closely. This is because there were no clinical findings that would indicate kidney concerns.
69. Our adviser said Mr M’s blood pressure was a little low. They said if Mr M’s blood pressure would have been persistently low then clinicians would have had a reason to keep a close eye on urine output.
70. Sadly, Mr M died quiet shortly after being admitted and there is no record of a persistently low blood pressure.
71. Based on independent clinical advice and on medical records, we are of the view there was no clinical necessity to keep a record of fluid input and output.
72. In summary, based on evidence we have seen so far, we have found the Trust offered Mr M care and treatment in line with NICE guidance for pulmonary embolism. We also found the Trust offered intravenous fluids and antibiotics, monitoring and screening in line with NICE [NG51] as it suspected sepsis. We have not seen any evidence that the time stamp in respect to starting the sepsis bundle had any detrimental impact on the care the Trust provided. As such, we do not propose to uphold this part of the complaint.
Care and Accuracy of records
73. Mr M’s family are unhappy with the way the Trust kept clinical records. Mrs M had a meeting with the Trust during the local complaints process and was able to identify instances when clinical observations were made but no signed or timestamped or when the Trust provided medication but the time recorded does not correspond exactly with the clinical recommendations.
74. Mrs M explained she is of the view this indicates the Trust did not provide suitable and timely care and this contributed or led to her husband’s death.
75. Based on our review of the medical records and the symptoms Mr M presented with, we are of the view the Trust provided monitoring, care and treatment in line with guidance. The lack of time recording or the lack of a sepsis bundle or the lack a fluid chart of the did not impede the Trust to provide care and treatment in line with NICE ‘Pulmonary embolism’ guidance and in line with NICE [NG51].
76. We recognise Mrs M is concerned the Trust did not accurately record the sepsis care bundle.
77. Based on NICE [NG51] we can see the Trust treated Mr M for suspected sepsis with intravenous fluids, intravenous antibiotics. As such, the management plan/ care plan was in line with NICE [NG51].
78. Mrs M also complains it is not clear from the medical records when the Trust administered Mr M’s medication and if this was done at the correct times. She is particularly concerned the anticoagulant medication was not administered correctly. Mrs M says as the anticoagulant medication was administered between 7am and 8am, soon after admission, and then at 8.05pm. She says the second dose of anticoagulant medication should have been administered between 5pm and 7pm.
79. NICE guidance on the treatment of pulmonary embolism and the administration of anticoagulants recommends clinicians should administer enoxaparin twice a day, it does not state the medication should be administered exactly every 10 or 12 hours.
80. Our adviser reviewed Mr M’s drug chart and the notes clinicians made during this admission and confirmed the Trust prescribed treatment and administered medication in line with Mr M’s needs and established clinical practice.
81. We recognise Mrs M is concerned not enough detail was included in the clinical notes about the administration of medication and she is of the view this contributed to poor care.
82. We are pleased to see the Trust administered anticoagulant medication twice a day in line with NICE guidance on pulmonary embolism.
83. Based on independent clinical advice, clinical records and NICE guidance on pulmonary embolism we are of the view the Trust administered suitable and timely treatment.
84. Regarding the record of the time of death, Mrs M feels the records are contradictory and therefore Mr M’s time of death is unknown. The family say this ambiguity has ‘tortured’ them with thoughts of Mr M being ‘alone and scared’ when he died.
85. The Trust investigated this matter and apologised for not being able to confirm the name of the person that was with Mr M at the time of death.
86. Nursing staff recorded Mr M was settled during the evening but that he became unwell at 9:55pm. Nursing staff recorded a nurse went to call the doctor leaving Mr M with a colleague. When the nurse returned, five minutes later, Mr M had sadly died and the nurse recorded this. It is recorded upon the nurse’s return, five minutes later, Mr M had died.
87. We recognise lack of clarity in respect to who was with Mr M at the time of death led Mrs M to question if indeed any member of staff was presented.
88. We accept this is distressing for Mrs M and we also can see this has added to her bereavement.
89. Based on the information included in the medical notes and based on the Trust’s complaint investigation we can see we are unable to determine which staff was with Mr M at the time of his death.
90. Based on what we have seen in the medical records, we accept better record keeping would have provided clarity and reassurance in respect to who was able to provide care and support during Mr M’s last moments.
91. As such, we consider there was a missed opportunity to provide reassurance and clarity due to poor recordkeeping.
92. The Nursing and Midwifery Council’s Code of practice state nursing staff should keep clear and accurate records. The Code details it is important to keep records relevant to the practice to enable colleagues to have everything they need.
93. We accept the records kept at the time of death did not have an impact on Mr M directly. We are mindful the details in the records did not assist the Trust’s complaints team to provide clarity during the complaints process.
94. We accept this has an impact on Mrs M as she will never be able to confirm if someone was with her husband when he died.
95. Based on medical records and Mrs M’s account we can see it was important for her to be with her husband and the lack of clarity in the medical records cannot provide reassurance in respect to this aspect of the complaint.
96. As such, we are of the view there was a lack of opportunity for the nursing staff to make detailed records at around the time of death to enable colleagues to have the necessary information when responding to the complaint.
97. Based on the evidence we have seen so far, we are of the view this had an impact on the Trust investigation and the Trust could not reconcile the medical records with the staff on duty at the time and moreover it continues to have an impact on Mrs M as she remains unsure of who provided comfort during her husband’s last moments.
DNACPR decision
98. A Do Not Attempt Cardiopulmonary Resuscitation order (DNACPR) is a document that formalises decision-making about whether an individual should be treated with CPR (chest compressions), in the event of a cardiac arrest (heart attack).
99. Mrs M says the Trust imposed the DNACPR decision on Mr M without facilitating his request to discuss it with his wife. Mrs M says the Trust communicated the DNACPR decision to her and son in a way which added unnecessarily to their distress.
100. GMC’s ‘Treatment and care towards the end-of-life’ is relevant as it provides guidance on DNACPR decisions for clinicians looking after patients with advanced, progressive and incurable diseases, like Mr M’s cancer diagnosis.
101. GMC’s ‘Treatment and care towards the end-of-life’ details DNACPR is a medical decision and can be made irrespective of whether or not a patient, or those close to the patient, agree with the decision (paragraphs 138 and 140). This is because a person cannot insist that they receive a treatment that a doctor does not think the patient should have. It is expected that a patient (or, in the case of a patient without capacity, someone close to the patient) is involved in the discussion and informed of the decision. In this context, involved does not mean that they are making the decision, but that the benefits and risks of the resuscitation are explained.
102. We recognise the lack of a consultation between Mr and Mrs M in respect to the DNACPR prior to the clinical decision led to distress.
103. Based on the above guidance, we can see DNACPR is mainly a medical decision as such, the Trust has no obligation to consult with Mr and Mrs M prior to the decision.
104. Our clinical adviser explained based on Mr M’s clinical picture, the decision not to resuscitate was in line with established clinical practice.
105. Mrs M also complains about how this decision was communicated and explained this led to distress.
106. We recognise Mrs M is of the view the Trust did not follow the GMC’s Good medical practice guidance when discussing DNACPR with her. She is doubtful the Trust communicated with Mr M in line with GMC’s Good medical practice.
107. We also recognise Mrs M felt the doctor informing her of the DNACPR decision was ‘aggressive, hurried and deliberately shocking.’ Mrs M describes how the doctor provided ‘a vivid description of broken ribs, brain damage and ‘dying anyway’’.
108. Based on Mrs M’s account we are pleased to know the doctor explained the risks of resuscitation. We find this was in line with GMC’s ‘Treatment and care towards the end-of-life’.
109. We recognise the details of resuscitation can be extremely unsettling. We do not doubt Mrs M was shocked to hear about side effects of resuscitation and we recognise Mrs M felt the manner in which the information was provided was aggressive.
110. We also recognise doctor have to deliver unsettling details about the burden, risks and benefits of resuscitation in line with GMC guidance.
111. Mrs M also complains the Trust did not facilitate a discussion between Mrs and Mr M about the clinical decision not to attempt resuscitation.
112. We recognise it must have been very distressing to find out about the clinical decision not to resuscitate. We also understand Mrs M was keenly aware her husband was very vulnerable and had some doubts about his capacity to make informed decision because he was extremely unwell.
113. Medical records detail Mrs M was very distressed when she was advised about the decision to not resuscitate. Records also detail she asked the Trust to facilitate a discussion between her and her husband. It is recorded clinicians returned to Mr M to check if he understood the decision not to resuscitate and at this stage, it is recorded, he agreed with the decision and he wanted to communicate with Mrs M himself. It is also recorded Mr M understood his wife was not happy with the DNACPR decision.
114. GMC’s Good Medical Practice guidance sets out the principles, values, and standards of professional behaviour expected of all doctors. It covers areas that include making the care of patients the first concern and working in partnership with patients and supporting them to make informed decisions about their care. The guidance focuses on the way a clinician should communicate with patients and loved ones. The guidance does not provide any detail on respect to clinicians facilitating family members to discuss clinical decision.
115. As such, we are pleased to see the Trust acted in line with GMC’s Good Medical Practice, sections 15 to 37. Specifically, listen and recorded Mrs M wishes when she advised the Trust she would like to have a further conversation with her husband about the DNACPR decision.
116. In summary, based on evidence we have seen so far in GMC’s ‘Treatment and care towards the end-of-life’ and Good medical practice guidance, we do not propose to uphold this part of the complaint.
Phone lines
117. Mrs M says in the afternoon the family tried to contact the ward to find out more details about the care and treatment the Trust was providing but ‘staff deliberately picked up the receiver and then placed it down again to clear the line’ and the family states this happened several times.
118. The Trust apologised for not answering the phone and explained it has taken action and ordered portable phones to allow nursing staff to take calls whilst in the bays caring for patients.
119. We considered under previous headings the communication between the Trust and Mr M’s family in respect with updating them on care and prognosis. We consider this was in line with GMC guidance.
120. We are mindful hospitals can become very busy and sometimes clinicians do not have time to staff phone lines as they are required to address any medical emergencies that arise at any given moment.
121. We accept Mr M’s hospitalisation was a very worrying time and we also accept the inability to obtain clarifications and updates must have exacerbated the worry Mr M’s family felt.
122. We are pleased to see the Trust has accepted the this has led to distress and has apologised for this.
123. As such, it is our consideration the action the Trust took following the complaint, along with the apology, are in line with our Complaint Standards and put right the impact of this part of the complaint. For these reasons, we do not propose to uphold this part of the complaint.
Clexane
124. Mrs M says the Trust administered more Clexane then required and this has led to her husband’s deterioration.
125. According to British National Formulary 80, 1mg/kg twice daily of enoxaparin sodium (Clexane) is recommended for the treatment of pulmonary embolism in patients with risk factors such as obesity, symptomatic pulmonary embolism and cancer.
126. According to the Trust’s complaint response, Mr M received 1.5 times the above dose when he was prescribed Clexane in the emergency department.
127. Our adviser reviewed this dosage and advised a single excess higher dose is unlikely to make a clinical difference.
128. We acknowledge finding out Mr M received more than the recommended amount of enoxaparin sodium would be distressing for Mrs M.
129. We would like to reassure Mrs M we reviewed the clinical literature in respect to enoxaparin overdose and cancer. We have not found any clinical review that focused on these specific issues.
130. We have found details which show an enoxaparin overdose is generally managed though clinical observation and intervention if necessary. We are mindful this clinical resource (Zhou FN, Gellatly RM: ‘Management of an unintentional enoxaparin overdose: A case report and literature review’, 2023) has become available in 2023 as such, it was not available to clinicians at the time Mr M was hospitalised.
131. Based on medical records, we can see the Trust monitored Mr M’s vital signs and his overall clinical picture improved after Mr M received enoxaparin sodium in the emergency department.
132. Based on clinical observations following the enoxaparin sodium administration in the emergency department and considering the independent clinical advice, we are of the view, on the balance of probability the single excess higher dose administered in the emergency department did not have a detrimental clinical impact. As such, we do not propose to uphold this part of the complaint.