2018 admission
26. On 26 October 2018, Mrs A attended the A&E department at the Trust. During this admission Ms A stayed with her mother in hospital, for the full admission period, with irregular trips home.
27. On 1 November 2018, Mrs A was transferred to a different Trust.
Repositioning
28. Ms A told us her mother was not repositioned at all. We can understand Ms A’s concern as she told us the impact of these failings contributed to her mother’s grade three pressure sore and skin tear. Ms A told us she discovered the grade three pressure sore and skin tear five days later.
29. Medical records document on admission, the Trust completed a pressure ulcer risk assessment. This is a risk assessment tool which assesses a patient’s risk of developing a pressure sore. Following this assessment, the Trust determined Mrs A was at ‘very high risk’ of developing a pressure sore. Consequently, The Trust implemented a pressure ulcer prevention care plan which said Mrs A needed two hourly positional changes.
30. Medical records show on admission, the Trust also completed a body map. This is a picture, front and back of the whole body, where clinical staff identify and mark on the body map any wounds or pressure sores, red areas, burns or other marks. The body map identified Mrs A’s sacrum (lower back, just above the bottom) area was red but the skin was intact.
31. Medical records document the following in respect to pressure care: • 26 October positional changes but not occurring every two hours as should be • 27 October Mrs A remained on her back during the day. Records document positional change occurred late at night, however the skin condition is not documented in the nursing notes.
• 28 October not changed position every two hours, skin condition is not documented • 29 October no positional changes or skin condition recorded. We note there is documentation of two hourly rounds, but no reference made to position or positional changes • 30 October remains on back day and night no positional change or skin condition in notes • 31 October, Mrs A remained on her back throughout the day and was on her side during the evening. Skin condition is not described in the notes. Pressure sore and sacral tear are not recorded.
• 1 November Mrs A remained on her back all day. Last recorded observation was 2pm and skin condition is not described in the notes. Pressure sore and sacral tear are also not referenced.
32. Medical records document Mrs A’s daughter declined some positional changes for her mother on two days. Medical records detail, on the day of admission, Ms A ‘preferred her mother to be on her back in a sitting up position’. It is also documented, on 31 October 2018, ‘daughter refused mum to be repositioned, she said mum is comfortable’.
33. There is no evidence in the medical records, the Trust advised Mrs A or her daughter of the potential risks in not repositioning even though two hourly ward rounds were maintained.
34. The Trust transferred Mrs A on 1 November 2018, to a specialist respiratory ward in a different Trust.
35. The ambulance service recorded Mrs A pressure ulcer and skin tear. The respiratory ward recorded Mrs A had a category three pressure ulcer.
36. The Trust’s guidance for pressure care says a SSKIN bundle (a bed assessment tool to help staff monitor skin concerns and proactively reduce the risk of a patient developing pressure ulcers) should be used to demonstrate positional changes in patients ‘at risk’ of pressure area damage.
37. NICE [CG179] sets out what should happen when giving pressure care. It says, ‘adults who have been assessed as being at high risk of developing a pressure ulcer are to change their position frequently and at least every four hours.’ The guideline also recommend clinicians should document the frequency of repositioning required.
38. Nursing Standards BNMC, section 2.10, says nurses should ‘provide information in accessible ways to help people understand and make decisions about their health, life choices, illness and care’. In other words, patient preferences should be acknowledged and nursing staff should advise of the risks so the patient can make an informed decision.
39. NMC’s ‘Future Nurse: Standards of proficiency for registered nurses’, section 1.16, detail nurses should complete clear accurate and timely records.
40. Based on the medical records we have seen, and the irregular documentation in respect to repositioning, we are of the view it is more likely than not the Trust did not turn Mrs A every two hours as recommended by the Trust in Mrs A pressure care plan. We consider this was not in line with the pressure care plan proposed by the Trust on admission.
41. Based on the medical records we have seen, the Trust completed Mrs A’s SSKIN charts. Each time it has marked Mrs A had ‘a redness/discoloration presented’ it has missed the opportunity to describe this finding in the daily evaluation as indicated in the SSKIN chart. As such, at this stage, we are of view the Trust was unable to evaluate any skin deterioration due to poor record keeping. We consider this is not in line with NMC’s ‘Future Nurse: Standards of proficiency for registered nurses.’
42. We recognise both Ms A and the nursing staff wanted to keep Mrs A as comfortable as possible and it is possible this is the reason why she was not turned as regularly as recommended.
43. We are mindful the Trust assessed Mrs A as high risk of developing pressure ulcers and implemented a care plan to try to prevent this from happening.
44. Based on nursing standards, we also consider, the Trust should have informed Mrs A and her daughter of the risks of Mrs A maintaining the same position.
45. We have not seen any record of the skin tear and pressure sore in the Trust’s records. The evidence which showed the pressure sore and skin tear came from ambulance records and hospital records from another Trust as well as photographs supplied by Ms A.
46. We have seen failings in pressure care and signs a pressure sore was forming as early as 26 October 2018.
47. We need to consider if a lack of turning can cause a pressure sore to form.
48. NHS England’s ‘pressure ulcers’ explains pressure ulcers can develop when a large amount of pressure is applied to an area of skin over a short period of time.
49. Our nurse adviser explained the time it takes for a pressure ulcer to form depends on two main factors; the amount of pressure and how vulnerable the person’s skin is to damage. This means, in susceptible people, a full-thickness pressure ulcer can sometimes develop in just one or two hours. However, in some cases, the damage will only become apparent a few days after the injury has occurred.
50. Based on the evidence we have seen, particularly Mrs A’s pressure ulcer assessment and NHS England’s guidance on pressure ulcers, we are of the view it is more likely than not that the lack of repositioning contributed to the formation of Mrs A’s pressure sore.
51. Ms A also informed us her mother developed a sacral tear (open wound at the sacrum) by the time she was transferred to a different Trust.
52. We can see from NICE guidance on pressure ulcers, skin tears are caused by shearing forces. Shearing forces can be a result of downward pressure and friction which occurs at the deeper layers of the skin tissue.
53. We are of the view, the lack of repositioning alone did not result in the skin tear, as other factors such as underlining health conditions are also a contributor.
54. Mrs A says her mother’s suffering caused her significant distress. She says lack of repositioning led to the formation of the pressure sore which in turn contributed to her mother having to remain bed bound until her death which meant Ms A had increased caring responsibilities.
55. We consider there was a missed opportunity to document and describe the condition of Mrs A’s skin and it is more likely than not Mrs A was not repositioned every two hours and initially assessed by the Trust.
56. We are mindful, if Mrs A skin condition would have been recorded and evaluated daily, the Trust would have been potentially in a better position to spot and assess any skin deterioration sooner. As such, at this stage, we are of the view there was a missed opportunity to identify skin deterioration and provide alleviating treatment sooner.
57. Medical records detail, on admission the Trust assessed Mrs A at very high risk of developing pressure ulcers due to her restricted mobility, weight and underlining health conditions.
58. NICE [CG179] explains patients are at risk of developing pressure ulcers if there have multiple risk factors (for example limited mobility).
59. We are mindful that NICE [CG179] provides guidance on steps clinicians could take to try to prevent pressure ulcers, however the guidance does not confirm that the prevention methods will categorically exclude the development of pressure ulcers. The guidance explains the preventions methods and continues to explain the management of pressure ulcers if the prevention is unsuccessful. As such, the guidance accepts that despite the prevention methods, pressure ulcers can still develop in patients at risk and at high risk of developing a pressure ulcer.
60. We accept Ms A’s account that her mother was able to live a full life with her assistance.
61. We also accept based on Mrs A’s clinical picture (age, weight and underlining health conditions) she had restricted mobility.
62. Based on the evidence we have seen so far, we consider the Trust’s assessment of Mrs A’s mobility was accurate and this represented one of the risk factors in the assessment the Trust carried out.
63. Based on NICE guidance on pressure ulcers, we are of the view Mrs A’s very high risk of developing pressure ulcers could have been addressed by the care plan the Trust proposed. We are also mindful the risk of pressure ulcer would not have been entirely excluded even with NICE recommended care.
64. At this stage, we have seen evidence to indicate the Trust recommended pressure ulcers care plan in line with NICE [CG179] and the Trust’s policy. Sadly, we have also seen there was a missed opportunity to implement pressure ulcer care in line with Trust’s policy.
65. As such, we are of the view, due to Mrs A’s very high risk of developing a pressure ulcer, it is more likely than not that her skin would have deteriorated despite preventative care. As such, based on evidence we have seen so far, we are unable to say with certainty that the delay in pressure ulcer and sacral skin tear was the cause of Mrs A remaining bed bound.
66. Due to the lack of detailed documentation in the medical records, we unable to determine, based on medical records, when the pressure ulcer developed or the skin tear occurred.
67. Based on independent clinical nursing advice from our nurse adviser and Mrs A’s risk factors, we have seen it is possible for pressure ulcers to develop within one or two hours. As such, at this stage, we are unable to exclude the possibility that Mrs A was not in pain from the time of admission until her transfer. Consequently, we are of the view, it is possible she could have been in pain for five days.
68. We acknowledged the Trust has undertaken a pressure ulcer improvement plan. The Trust confirmed it now completes three times weekly reviews of all patients at risk of developing pressure ulcers or at risk of deterioration. In addition, the Trust has also undertaken a pressure ulcer quality improvement project on the reduction of pressure ulcers.
69. Our Principles of Remedy say where something has gone wrong and this has had an impact, the organisation should take action to put things right. In this case the Trust has apologised and recommended service improvements. We also consider further steps can be taken to remedy Mrs A’s distress.
Bed Pan
70. Ms A says the Trust left her mother on a bed pan for several hours causing a sacral tear and contributing to a pressure sore, an injury which meant Mrs A remained bed bound until her death.
71. Ms A told us sometime in the morning on 30 October 2018 she had left her mother’s room for approximately 45 minutes. Ms A believes this is when the Trust offered her mother the bed pan. Later that day her mother was complaining of discomfort in her sacrum area and Ms A said she asked staff for help but there were no nurses available.
72. Ms A told us her mother was in increasing pain and a friend came to the hospital to help. They found it difficult to turn Mrs A but eventually turned her and saw the damage to her sacrum area and found the bed pan. Ms A deduced the bed pan must have been there for about seven hours as she had not seen the nurse place the bed pan and that was the last time she left the room.
73. The Trust concluded following its investigation it cannot say how long the bed pan was left for. As a result of this complaint, it said further incidents will be documented on the incident reporting system and it will ensure ward staff check frequently on patients who have been left using a bed pan.
74. Ms A provided photo evidence, friend’s witness statement and her account to evidence her mother’s sink tear happened on 30 October 2018 when the Trust left Mrs A on the bed pan for a few hours. Ms A considers it was cruel to transfer her mother on 31 October 2018 on the bedpan taking into account Ms A already had evidence her mother had a skin tear.
75. Medical records document, on 29 October 2018, Mrs A had an enema as she was ‘very very constipated’. Medical records do not document the condition of Mrs A’s skin at the time the Trust administered the enema on 29 October 2018.
76. On 30 October 2018, medical records document: • 1pm a doctor recorded they spoke with Ms A and she complained her mother had been left on a bed pan for over six hours • 1.30pm the nursing notes say ‘daughter complained that her mum was left on a bedpan for two hours. ‘I offered to take off bedpan but patient refused in the presence of daughter. Wants to stay on the bedpan for more time’ • 3.30pm, the nursing records detail ‘Ms A complains that her mother was feeling something slippery under her bottom and that Ms A could not reposition her even with an assistant to look at the area’. The notes detail ‘sacrum area could not be assessed’.
• 5pm Mrs A’s stool was assessed using a stool chart and was found to be type 1 which indicated constipation.
77. Medical records do not document when the bed pan was placed and removed, we cannot say exactly how long Mrs A was on the bed pan for.
78. We are sorry to hear the Trust was not able to assist Mrs A when her daughter notified the Trust her mother was in distress due to lack of turning and the presence of the bedpan.
79. Based on medical records, dated 30 April 2018, we consider it likely Mrs A used the bed pan for an extended amount of time. Based on medical records and Ms A’s account we are of the view it is more likely than not the Trust offered Mrs A the bed pan sometime in the morning and removed it around 5pm when it assessed the stool.
80. Sadly, the medical records do not detail the condition of the skin when the bedpan was removed nor do they document Ms A’s findings. We would expect medical records to record Ms A’s statement that she discovered a skin tear on her mother sacrum, on the day.
81. The Royal Marsden Manual of Clinical Nursing Procedures guide sets the standard for nursing care, providing the procedures, rationale, and guidance required by qualified nurses to deliver clinically effective, patient-focused care with expertise and confidence. The guide states nurses should ‘Ensure that toilet paper and a call bell are within the patients reach and leave the patient but remain nearby’.
82. Our nurse adviser explained the patient should not feel rushed and frequent checking can cause embarrassment for the patient. The patient’s privacy and dignity should be respected when provided continence care.
83. Unfortunately, there is no guidance as to how long a patient should be left on a bed pan for, we have seen the nurses checked in on Mrs A who requested more time.
84. We know Mrs A was visited frequently by various clinicians on 30 October 2018 and Ms A was with her during most of the day. Mrs A was not simply left on her own and members of staff were available to be alerted. We consider Mrs A was left to use the bed pan as per the relevant guidance discussed.
85. We accept what our nurse adviser told us and are mindful of Mrs A’s age. We also recognise there is no documentation to detail Mrs A’s skin condition.
86. We know Mrs A had fragile skin. We have seen in the previous head of complaint pressure ulcers care formed by pressure forces or pressure in combination with shear. We consider it is more likely than not Mrs A experienced friction or shear forces whilst on the bed pan and this most likely contributed to the skin tear.
87. We are mindful Mrs A needed the bed pan due to constipation and enema. We are also mindful, as before, that even with the greatest of care taken, skin damage in vulnerable patients can occur.
88. We have seen the skin tear was not recorded and we know the nursing and midwifery code says nurses should act immediately to put right a situation where someone has suffered harm, explain and apologise to the person affected and their carers.
89. As such, based on the evidence we have seen so far, we are of the view the Trust acted with consideration by not rushing Mrs A when she was on the bedpan and we found this is in line with The Royal Marsden Manual of Clinical Nursing Procedures guide.
90. We are aware that Mrs A was moved while on the bed pan, on 31 October 2018. The Trust accepted this should not have happened and apologised.
91. Based on the independent clinical nursing advice we received, we also consider the hospital transfer, whilst using a bed pan is not in line with established nursing practice as it can compromise patients’ dignity.
92. We are pleased to see the Trust apologised for moving Mrs A while on the bed pan.
93. Based on evidence we have seen, we are of the view, the extended use of the bed pan together with the bed transfer, more likely than not contributed to a skin tear.
94. We recognise Ms A’s view that pressure ulcer treatment, particularly, barrier cream, could have prevented the pressure ulcers or the skin tear. Based, on NICE pressure care guidance, we can see that even with recommended care, skin deterioration can occur in high risk patients such as Mrs A. We recognise there are no records that document the application of barrier cream. As such, we cannot say with certainty the lack of the barrier cream contribute to the skin tear or pressure ulcer. We consider the skin deterioration, pressure ulcers and skin tear, contributed to discomfort and pain.
95. Our Principles of Remedy say where something has gone wrong, and this has had an impact, the organisation should take action to put things right. In this case the Trust has apologised and recommended service improvements. We also consider further steps can be taken to remedy Mrs A’s distress.
Diuretic
96. Ms A says the Trust withdrawn her mother’s diuretic medication which caused her to limbs to swell with fluid. This caused her pain discomfort and put her health at risk. Ms A says the diuretic should not have been stopped.
97. Ms A says her mother’s daily dose of diuretic medication was usually split into a morning and an afternoon dose. This was because she could not tolerate taking it as one dose. Ms A said she informed the doctors of this and they did not listen to her.
98. Ms A explains the Trust reinstated the diuretic medication but as a single daily dose. Ms A believes her mother suffered a peri arrest due to this clinical decision.
99. The Trust says any physical deterioration seen immediately after Mrs A received the diuretic was unlikely to be related to its withdrawal and restarting as diuretic tablets do not work that quickly on the system. It says the timing of the administration of the tablets and Mrs A’s deterioration was likely to be coincidental.
100. Medical records document the medication Mrs A was on at the time of admission. It is document Mrs A was taking bumetanide 2mg per day. Bumetanide is a diuretic medication. Diuretics are drugs that increase urine production and are used to treat oedema (swelling), hypertension (high blood pressure), and heart failure.
101. Records document, Mrs A presented with high temperature and tenderness over her lower abdomen. It is recorded a urine dipstick test returned positive result for infection. As such, the Trust provided a working diagnosis of urinary tract infection (UTI).
102. Medical records also detail on admission, the Trust undertook blood tests which showed acute kidney injury.
103. Medical records for 26 October 2018 document, Mrs A’s diuretic medication was stopped.
104. On 31 October 2018, Mrs A’s diuretics were reinstated. Soon after Ms A saw her mother was having trouble breathing and was struggling so she pressed the emergency button next to her mother’s bed, alerting the doctors.
105. NICE [CG169] covers preventing, detecting and managing acute kidney injury in children, young people and adults. This guideline are relevant to Mrs A’s case as Mrs A’s blood tests showed she had acute kidney injury and the management of this condition is essential in preventing further deterioration.
106. NICE [CG169] recommends clinicians consider removing diuretics in patients with acute kidney injury.
107. NICE ‘Heart failure: prescribing information -diuretics’ provides details on the preferred diuretics for patients with heart failure. This guidance is relevant to this case because Mrs A had a diagnosis of heart failure with typical symptoms (breathlessness, ankle swelling, and fatigue) and signs (peripheral oedema).
108. NICE ‘Heart failure: prescribing information -diuretics’ recommends clinicians review bumetanide dose and adjust as necessary to reduce the risk of dehydration and acute kidney injury.
109. Our geriatric adviser confirmed the decision to remove Mrs A’s diuretics was clinically appropriate due to Mrs A’s acute kidney injury and the UTI. They explained it is important to avoid dehydration in patients with active infections. As such, it would have been important to stop any medication, like diuretics, that would have led to dehydration due to the active UTI.
110. At this stage, based on independent clinical advice and NICE [148] we are of the view the Trust acted within the established clinical practice and in line with relevant guidelines, NICE [CG169] and NICE ‘Heart failure: prescribing information -diuretics’, when it withdrawn Mrs A’s diuretics on admission.
111. Medical records document, on 28 October 2018, Mrs A was improving as her basic vital checks measurements were improving compared with the measurements at the time of admission.
112. Based on medical records, we have seen the Trust reinstated Mrs A’s diuretics, originally prescribed for or the management of oedema due to heart failure, on 31 October 2018.
113. NICE ‘Heart failure: prescribing information -diuretics’ also recommends clinicians reintroduce the treatment for heart failure once the risk of dehydration has been reduced. The guidance also recommends bumetanide ‘is usually given once a day, in the morning, but it can be given twice a day (morning and lunchtime) for additional diuresis.’
114. Based on Mrs A’s medical records, we have seen Mrs A was prescribed antibiotics, and these were helping Mrs A fight the UTI. Mrs A overall condition was improving.
115. As such, based on medical records, we are of the view the Trust acted in line with NICE ‘Heart failure: prescribing information -diuretics’ when it reached the decision to reintroduce diuretics once a day.
116. Ms A told us her mother’s diuretic medication was usually given as a split dose and giving her the full dose of diuretics caused her to have a peri arrest.
117. A peri arrest is a term used to describe when a patient is acutely unwell and needs urgent attention usually to prevent a full cardiac arrest (heart attack).
118. We recognise it must have been a very distressing time for Ms A to see her mother deteriorate rapidly soon after the diuretics were reinstated.
119. We are sorry to hear her mother had a peri arrest. We can see from speaking with Ms A this event had a lasting impact on her own mental health.
120. BNF 76 guidance for bumetanide says bumetanide medication can be given as a split dose or as a whole dose. We looked at the side effects of taking bumetanide described in the BNF and did not see it would have caused Mrs A’s symptoms.
121. NHS England ‘Common questions about bumetanide’ says ‘bumetanide starts to work within one hour, but it may take a few weeks to fully take effect.’
122. Our geriatric adviser explained it is not possible for bumetanide to cause the symptoms Mrs A sadly experienced.
123. Based on medical records, the diuretics were administered 25 minutes before Mrs A’s clinical deterioration. Our geriatric adviser explained a diuretic may start working at 30 minutes and it takes one to two hours to reach peak effect.
124. In summary, we have seen the Trust acted in line with BNF 76 and NHS guidance ‘Heart failure: prescribing information -diuretics’, when it recommended the withdrawal of diuretics. Based on the evidence we have seen, we also consider the Trust acted in line with the above guidance when it reinstated the diuretics. Furthermore, we have not seen any evidence that would suggest the diuretic prescribed could have led to the symptoms Mrs A experienced during the peri arrest.
125. We do not propose to uphold this part of the complaint.
Second admission – March 2019
Oxygen reduction
126. Ms A says the Trust made the decision to reduce her mother’s oxygen to one litre per minute. She says her mother was well and talking normally when suddenly she stopped talking and her lips had gone purple. The Trust re-positioned Mrs A in bed and turned back up her oxygen to two litres per minute. Ms A told us her mother had been de-saturating (a drop in oxygen in the blood) for approximately 20 minutes and it took her a while to recover.
127. Ms A says her mother was due to be discharged on the 13 March 2019 and because of this incident her mother’s stay in hospital was prolonged. She says her mother’s oxygen should never have been turned down and Mrs A had to be constantly on two litres of oxygen per minute, Ms A says her mother’s oxygen was prescriptive.
128. Ms A says she provided the Trust, at the time of admission, a bundle of her mother’s medical reports from all of her consultants and recent prescriptions. She also says she spoke with her mother’s consultant from a different Trust and the consultant kindly offered a 24 hours service where treating clinicians could get in touch if they needed any clarification.
129. Ms A argues based on the bundle she provided, the open line of communication with the respiratory consultant from a different Trust and her expertise, the Trust should have known her mother’s oxygen prescription should not have been reduced.
130. Medical records show the Trust recorded Mrs A’s oxygen requirement. Emergency department records detail Mrs A had urosepsis, it also recorded Mrs A’s past medical history and medications. Specifically, the Trust recorded Mrs A was on a BiPAP, eight hours over night and she was on oxygen 24 hours a day at a rate of two litres per minute.
131. The Trust moved Mrs A from the emergency department to a ward, on the day of admission. The ward admission pro-forma detailed Mrs A was on long term oxygen at a rate of two litres per minute, NIV (non-invasive ventilation, via a mask) at night and two litres of oxygen.
132. On 11 March 2019, following a medical review the Trust decided to turn Ms A’s oxygen down from two litres per minute to one litre per minute.
133. BNF 77 ‘Oxygen’ explains oxygen should be regarded as a drug. It is prescribed to increase alveolar oxygen tension and decrease the work of breathing. The concentration of oxygen required depends on the condition being treated; the administration of an inappropriate concentration of oxygen can have serious or even fatal consequences.
134. BNF 77 explains long term oxygen therapy, such as that Mrs A was prescribed by her outpatient oxygen therapy team, can only be prescribed after a specialist detailed assessment that could take at least six weeks and should be reviewed every year.
135. BMJ research ‘Guideline for oxygen use in healthcare and emergency settings’ provides recommendations on effective prescribing and delivery of oxygen for patients. This guidance is relevant to Mrs A’s circumstances because she was on long term oxygen therapy. The guidelines detail it is recommended when a patient needs oxygen constantly it is usual for a patient to be given a letter from an outpatient oxygen team so they can give this to treating clinicians in the event of an emergency or hospital admission.
136. BMJ research also recommends clinicians should consider reducing oxygen in stable patients with satisfactory oxygen saturation. It details oxygen should be discontinued once the patient can maintain saturation within or above the target range breathing air. It states the oxygen prescription need for the patient to reach a target range should be left in place in case of future deterioration.
137. Our physician adviser explained the majority of people who are prescribed oxygen for COPD such as Mrs A, are on long term oxygen therapy. They advised in rare cases when a patient needs oxygen constantly it is usual for a patient to be given a letter from an outpatient oxygen team so they can give this to treating clinicians in the event of an emergency or hospital admission. Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions that cause breathing difficulties.
138. Based on medical records, we can see Ms A obtained a letter from the specialist oxygen therapy service on 16 May 2019, advising any clinicians treating Mrs A that she required constant oxygen. We recognise this letter was placed on Mrs A’s records after this admission and the clinicians treating Mrs A during this admission were not aware of the specialist clinical assessment she undertook or the outcome of this assessment.
139. We recognise Ms A remains upset the Trust did not take her advice on board. Ms A said she told the hospital staff what her mother’s oxygen requirements were and we have seen in the records she communicated this to the hospital staff as the oxygen requirements were recorded at various points in Mrs A’s medical records.
140. Based on medical records and Ms A’s account we can see Mrs A was on constant oxygen. We can see this was prescribed by a specialist team.
141. Sadly, at the time of this admission Mrs A did not have a letter from the specialist oxygen team to inform treating clinicians that she was on constant oxygen. As such, although Mrs A’s oxygen requirements were noted and Ms A’s advice was recorded in the medical records, clinicians did not have clinical evidence of the specialist oxygen therapy team’s recommendations.
142. Based on medical records, we seen Mrs A’s observations (oxygen saturation, blood pressure etc.) were stable. As such, in the absence of a letter from the specialist oxygen therapy team, the Trust acted in line with BNF 77 guidance and BMJ research when it recommended the reduction of oxygen.
143. Ms A told us she felt ignored as she was continually fighting to communicate with clinicians her mother’s clinical requirements.
144. We accept she was in a very difficult position as despite being her mother’s carer and being acutely aware of her mother’s long-term conditions. Ms A was not, however, a qualified clinician and was unable to provide clinical advice on her mother’s oxygen requirements to the Trust.
145. We are pleased to see the Trust recorded all the advice Ms A offered to clinicians and we consider this shows clinicians were willing to listen. We found this was in line with the Trust’s Carer Charter. Specifically, the notes made in the medical records demonstrate the Trust listened to Ms A’s expertise and acknowledged her expertise as a carer. We are mindful the Trust’s Carer Charter refers to the expertise of a carer not medical expertise of a clinician. As such, the Charter does not recommend clinicians listen to the carer’s expertise on medical matters.
146. We recognise it is Ms A’s firm belief the Trust should have consulted with the doctors form a different Trust and should have ascertain her mother was on continuous oxygen from the bundle of paper she provided on admission.
147. GMC’s Good Medical Practice states when providing good standards of medical care, clinicians should consider: • a patient’s medical history • presenting symptoms • propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when the prescribing clinicians has adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs • consult colleagues where appropriate.
148. We are satisfied, based on independent clinical advice, the Trust offered care and treatment in line with Mrs A clinical history and clinical picture at the time at the time.
149. We can also see the Trust took all the steps, medical history, Ms A’s carer expertise and advice, noted synonyms, to gain knowledge of Mrs A’s health to enable it to provide oxygen treatment in line with BNF guidance.
150. We can also see the Trust considered the input of a respiratory consultant but on this occasion did not consider it would have been appropriate to consider the input of a respiratory consultant from a different Trust.
151. It is our view, the steps the Trust took to gain an insight into Mrs A’s health, the treatment and the input from the respiratory consultant are in line with GMC’s Good Medical Practice standards.
152. We can see the specialist oxygen therapy service did not feel there was a clinical necessity to include a medical letter with the oxygen recommendations until after Ms A contacted it in May 2019, and effects of reducing the oxygen became clear.
153. We are mindful in respect to this point of the complaint, a treating clinicians required to undertake a clinical assessment over a number of weeks to determine Mrs A required constant oxygen or a clinical letter from specialist service.
154. We are sorry to hear of the impact the oxygen reduction had on Mrs A and we recognise this has led to anxiety and distress for both Mrs A and her daughter. From speaking with Ms A and from Mrs A’s medical records we can see she continuously advocated for her mother’s oxygen needs. We recognise this must have been draining and extremely stressful as she felt failure to be successful in her pursuit would mean mother would suffer an unnecessary respiratory arrest.
155. At this stage, based on evidence we have seen, we are of the view the Trust acted in line with BNF 77 and BMJ research when it reduced the oxygen. We do not propose to uphold this part of the complaint.
Oxygen disconnection
156. Ms A told us on 11 March 2019 the Trust advised it will be moving her mother to a different bed. Ms A explained due to this her mother’s oxygen was disconnected from the port in the hospital wall and connected to the oxygen tank under her mother’s bed. Sadly, the oxygen tank valve was not opened and this prevented oxygen from flowing, which in turn caused Mrs A to have an arrest.
157. Ms A told us this was a particularly distressing event, she was talking to her mother while they were walking down the corridor towards the hospital lift when suddenly her mother went quiet and she turned blue.
158. The Trust accepted this was an error and it apologised. It implemented a process by which staff need to check the oxygen valve is active before commencing transfer.
159. BNF 77 guidance says ‘oxygen may be supplied as oxygen cylinders. Oxygen flow can be adjusted as the cylinders are equipped with an oxygen flow meter with ‘medium’ (two litres/minute).’ Therefore, it was appropriate for Mrs A’s oxygen to be delivered via an oxygen cylinder during the move.
160. Medical records document, due to the lack of oxygen, Mrs A had what the Trust described as a respiratory arrest.
161. It is clear Mrs A suffered a serious event as a result of oxygen not being delivered and we understand this must have been extremely distressing and upsetting for Ms A to watch her mother become so very unwell.
162. From assessing Mrs A’s medical records we can see Mrs A was treated and thankfully did not go into a full arrest.
163. Ms A said this incident caused her mother to become hypoxic. Hypoxia is low levels of oxygen in the bodies tissues which is measured by the oxygen saturations in the blood.
164. Hypoxia can be caused by a condition which reduces the amount of oxygen in the blood. Some diseases like COPD, emphysema or asthma can put a person at risk of hypoxia.
165. Hypoxia is diagnosed using a blood gas test, this is where blood is taken and the oxygen levels in the blood are recorded providing oxygen saturation.
166. BTS guidance recommends for patients with known COPD target saturation range of between 88% and 92%.
167. BTS guidance recommends clinicians consider oxygen supplementation and treating underlining health conditions if hypoxia is diagnosed. The guidance also recommends clinicians monitor the patient and keep oxygen saturation within the target saturation range.
168. Based on medical records, Mrs A’s target oxygen saturation was between 88% – 92%, lower levels than these can indicate hypoxia.
169. Medical records document approximately an hour after the event, a doctor reviewed Mrs A and took her observations and her oxygen saturations were between 82-88%. These levels were low and indicative of hypoxia.
170. Medical records detail, 30 minutes later Mrs A’s oxygen saturations were recorded at 89% and we saw this was maintained.
171. Records show, the day after the event, Mrs A’s oxygen saturations were 91%.
172. On 15 March 2019 the Trust carried out a CT scan (a computer guided X-ray) to check of a hypoxic brain injury. The CT scan did not show any brain injuries.
173. Our respiratory adviser reviewed the medical records and confirmed there was no sustained hypoxia following this event.
174. Based on clinical records, we have seen, we are of the view Mrs A’s saturation started to decline soon after the oxygen was disconnected. We have also seen Mrs A’s oxygen saturation reached the target recommended level an hour and a half after the event.
175. Immediately following the oxygen disconnection, we have found Mrs A’s condition certainly worsened and she was in danger of having an arrest, fortunately a full arrest was avoided due to Ms A’s quick observations and the Trust’s quick action. We have not seen any evidence of prolonged hypoxia and we know Mrs A did not suffer a hypoxic brain injury, as a CT scan was carried out to check and a hypoxic brain injury was ruled out.
176. Based on the evidence we have seen, we are of the view it is more likely than not the lack of oxygen caused Mrs A to deteriorate and she required emergency treatment.
177. Based on medical records, we have seen the Trust supplemented and closely monitored Mrs A’s oxygen saturation levels when the oxygen saturation levels were not in the target rage, we find this is in line with BTS guideline.
178. We consider this event caused Ms A significant distress as she was concerned for her mother’s wellbeing.
179. We are reassured to see the Trust acted swiftly and prevent further deterioration. We are also pleased to see the Trust accepted there was a failing in respect to this part of the complaint, apologised and made recommendations for service improvements.
180. We consider the action the Trust took following the complaint, along with the apology, are in line with NHS 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.
Nebuliser
181. Ms A says her mother should not have been taken off oxygen to be given the nebuliser especially as there were two previous oxygen related incidents which caused her mother to desaturate. A nebuliser is device that can deliver high doses of medicine quickly and easily. It works by changing liquid medication into a mist to be inhaled.
182. Ms A explains a nurse who was taking care of her mother removed the oxygen canular (thin tubes) from her nose when giving a nebuliser, depriving her mother of oxygen for 20 to 30 mins.
183. The Trust apologised for this incident.
184. Records show, the Trust removed Mrs A’s oxygen canula to give the nebuliser.
185. Medical records also evidence there was no respiratory clinical letter provided prior to this admission or at the time of admission to advise clinicians that oxygen should not be disconnected while the nebuliser was given.
186. NICE [NG115] gives guidance for the delivery systems inhaled therapy during exacerbations says of and it says: ‘1.3.8 Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD.
1.3.9 The choice of delivery system should reflect the dose of drug needed, the person's ability to use the device, and the resources available to supervise therapy administration.’
187. Medical records detail, before the nasal canula was removed to deliver the nebuliser Mrs A’s oxygen saturation level was 93%, which is slightly above target. Medical records also detail oxygen saturations levels were monitored every two hours and they did not fall out of the BTS recommended range.
188. We understand Ms A would have been greatly distressed by this event especially as it was following a very serious oxygen related event only a few hours earlier.
189. We are also pleased to see the Trust accepted the nebuliser could have been administered while Mrs A was on oxygen in line with NICE [NG115]. We are also please to know the Trust identified potential service improvements in respect to communication between staff.
190. We consider the action the Trust took following the complaint, along with the apology, are in line with NHS Complaint Standards and put right the anxiety and distress Ms A experienced. For these reasons, we do not propose to uphold this part of the complaint.
Hypoxia
191. Ms A says the Trust did not treat her mother for hypoxia promptly and misdiagnosed her with delirium (a sudden change in mental function) instead. Ms A also says the Trust did not treat her mother for high carbon dioxide levels and diagnosed her as delirious for six days from the 12 to 17 March 2019.
192. Furthermore, Ms A also says because her mother’s oxygen was reduced or disconnected and had a peri arrest in March 2019 she had been suffering with hallucinations, judders, confusion and nightmares. Ms A says her mother’s hallucinations were so severe she spent the night trying to rip off her BiPAP and her mother needed 24/7 care.
193. Hypoxia is low levels of oxygen in the body’s tissues. Hypoxia, or low blood oxygen levels, can be tested using several methods: pulse oximetry and arterial blood gas analysis.
194. Pulse oximetry is a non-invasive test using a finger clip to measure oxygen saturation in the blood, parameter measured in the NEWS scoring system. Arterial blood gas analysis involves drawing blood from an artery to measure oxygen and carbon dioxide levels.
195. On 12 March 2019, medical records detail, Ms A raised concerns with clinicians that her mother’s confusion was due to the peri arrest from the previous day.
196. The Trust monitored Mrs A’s overall condition, throughout all Mrs A’s admissions, using the National Early Warning Score (NEWS). NEWS is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes.
197. The NEWS system scores physiological measurements which are routinely completed at patient’s bedside. The system measures: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new-onset confusion and temperature. The NEWS scoring system provides scores for a patient from 0 (no signs of deterioration) to 20 (indicating severe deterioration).
198. Medical records detail Mrs A’s target oxygen saturation was 88 – 92% oxygen saturation. Her observations were recorded regularly, a minimum of four hourly and sometimes as often as two hourly depending on her NEWS score. We do not have any concerns with the frequency of monitoring and consider Mrs A as appropriately monitored and the observations were recorded.
199. Medical records document Mrs A’s oxygen saturation on: • 12 March 2019 within range • 13 March 2019 within range • 14 March 2019 oxygen saturations fell to 83% for two hours and increased to 84% for two hours, • 15 March 2019 for two hours in the early evening oxygen saturations were at 94% which is above target, for the remainder of the day oxygen saturations were within range • 16 March 2019 for two hours in the evening oxygen saturations were at 93% and for another two hours they were at 94 % for the remainder of the day oxygen saturations were within range • 17 March 2019 in the early hours’ oxygen saturations were high for this day at 93% in the early hours of the morning rising to 98% in the afternoon. Her oxygen saturations were not below 93% all day • 18 March 2019 Mrs As oxygen saturations were high in the early hours reaching a level of 98%, they dropped to acceptable levels during mid-morning, but rose above the target of 92% in the afternoon and all evening • 19 March 2019 A’s oxygen was turned down as her oxygen saturations were too high and put her at risk of retaining oxygen.
200. On 18 March 2019, medical records document, Ms A went to see the respiratory team as she believed her mother to be hypoxic. Following this conversation, the Trust recommended a blood gas test. The result showed her mother was hypoxic and she was kept in hospital. The following day, the Trust transferred Mrs A to a respiratory ward.
201. NICE [CG103] covers diagnosing and treating delirium in people aged 18 and over in hospital and in long-term residential care or a nursing home. It also covers identifying people at risk of developing delirium in these settings and preventing onset. It aims to improve diagnosis of delirium and reduce hospital stays and complications. This guidance is relevant to Mrs A’s case as Mrs A was diagnosed with confusion and had underlining conditions that meant she was at risk of developing delirium.
202. NICE [CG103] details patients at risk of dehydration due to heart failure or chronic kidney disease are also at risk of delirium. It also details infection, hypoxia and reduced mobility would lead to an increased risk of delirium.
203. Based on medical records and Ms A’s account we know, Mrs A has chronic conditions, such as heart failure and chronic kidney disease, and her mobility was reduced. We also know, from medical records Mrs A was diagnosed with urinary tract infection.
204. Based on medical records, we have seen Mrs A had, during this admission, two episodes of hypoxia. One at the time of the peri arrest and one on 14 March 2019. Both episodes were limited in nature and oxygen saturation measurements as well as the CT scan evidence, it did not have a lasting impact on Mrs A.
205. Our respiratory adviser reviewed medical records and confirmed based on Mrs A’s symptoms Mrs A had delirium. They explain this is likely to be related to a combination of everything which had happened to Mrs A, probable infection, the low oxygen episodes, complex and multiple underlying medical conditions.
206. Based on medical records, we are of the view in the context of Mrs A’s underlining conditions it is difficult to say that episodes of hypoxia were the only cause that led to confusion/delirium. Based on evidence we have seen in NICE [CG103], in the balance of probability, it is more likely than not that other factors have contributed to Mrs A’s confusion, such as infection, acute kidney injury and heart condition.
207. As such, based on evidence we have seen, we consider the Trust addressed the episode when Mrs A was deemed to have low oxygen saturation, in line with BTS guidance. We also consider there was no lasting impact on Mrs A. We have also seen the episodes of hypoxia could have contributed to confusion and delirium and we have seen Mrs A underlying conditions represented a significant risk of delirium.
208. We do not uphold this part of the complaint as we consider the Trust monitored Mrs A’s oxygen saturation levels in line with the Royal College of Physicians recommendations and treated episodes of hypoxia between 12 March and 19 March 2019 in line with BTS guidelines.
Digoxin
209. Ms A says her mother was prescribed digoxin (medication to treat heart problems) when she already had stage four renal failure. Ms A says the use of digoxin put unnecessary strain on her mother’s kidneys and compromised her renal system.
210. Ms A explains the Trust prescribed her mother digoxin on 15 April 2020. Ms A says, at the time, she told the doctor that digoxin should not be used on a patient with renal failure and that it would hurt her mother’s kidneys.
211. Ms A says she voiced her concerns again on 18 April 2020 to a new consultant and at this stage, the consultant agreed with her and change the digoxin with bisoprolol (medication that helps the heartbeat more slowly with less force).
212. Ms A explains her mother sadly died a month later of fluid overload and an erratic heartbeat.
213. Medical records detail the Trust admitted Mrs A to hospital on 15 March 2020. The Trust found Mrs A has urinary tract infection (water infection), hyperglycaemia (high blood sugars) and an irregular heart rate. To treat the irregular heart rate, the Trust prescribed digoxin 500mg loading dose, on 16 March 2020. The Trust prescribed a maintenance dose of 62.5 micrograms once a day, between 17 March and 19 March 2020 to treat the irregular heart rate.
214. The Trust’s letter to Ms A’s GP informed the GP the Trust started a new medication, digoxin. The letter also recommended the GP to monitor for any signs of digoxin toxicity.
215. BNF 79 guidance says digoxin can be used for irregular heart rhythm and heart failure. The guidance states a loading dose should be considered in cases of irregular heart rate followed by a maintenance does. It details maintenance dose should be started on the day following the loading dose. The BNF says for patients with renal impairment clinicians are to consider reduced initial/loading and maintenance doses.
216. The above guidance indicates 62.5 micrograms per day is the lowest maintenance dose recommended for patients with renal impartment.
217. Following a review of medical records, our cardiology adviser confirmed the Trust prescribed digoxin loading dose and maintenance dose safely and appropriately.
218. We know Ms A was her mother’s carer for a very long time. We also know Mrs A delegated to her daughter the responsibility of interacting with medical professionals and advocating for medical treatment and care. Due to these reasons, Ms A was fully aware of her mother’s medical conditions and her mother’s general wellbeing.
219. We recognise it is Ms A’s firm belief her mother deteriorated and died due to poor medical care and treatment. We accept this view continues to cause Ms A significant distress. We are also mindful Ms A witnessed the treatment and care her mother received during the years and her view developed over time, by contrasting the care she provided with the care the Trust provide.
220. We accept Ms A provided her mother quality care as she was attuned to her needs. We are also mindful the Trust provided care and treatment in line with clinical guidance.
221. Based on BNF 79 guidance, medical records and independent clinical advice, we are of the view the Trust prescribed of digoxin appropriately and safely. As such, we do not uphold this part of the complaint.