Intensive care
19. Miss K complains the Trust refused to admit Mrs L to the intensive care unit (ICU). She tells us she is concerned that although Mrs L’s blood pressure was constantly extremely low, the Trust ignored this and did not admit her.
20. In its complaint response, the Trust said its Critical Care Outreach Team (CCOT) reviewed Mrs L on several occasions. It said based on the team’s assessments, Mrs L was not a suitable candidate to be ventilated as there was a low chance of recovery or good prognosis.
21. We acknowledge Miss K’s complaint concerns the Trust’s decision not to admit Mrs L to intensive care. We understand from our intensive care adviser that the main difference between the treatment Mrs L was receiving on the ward and what would have been available in an intensive care setting would have been ventilation (treatment with a ventilator, a machine that helps someone breathe by pushing air in and out of the lungs). We therefore focused our investigation of this part of Miss K’s complaint on how the Trust reached its decision Mrs L was not suitable for ventilation.
22. The guideline for the Provision of Intensive Care Services set out standards and recommendations for how intensive care units should operate, including the care they offer to patients. It says intensive care is defined by the level of support available to patients. This includes higher staffing levels, enhanced monitoring, and treatment with ventilation.
23. Our intensive care adviser explained the Trust was treating Mrs L with intravenous fluids to keep her hydrated and stabilise her blood pressure, and antibiotics to treat her infection. They said the only additional treatment the Trust could have offered Mrs L in an intensive care setting would have been support on a ventilator.
24. We understand from our intensive care adviser that when considering admitting a patient to intensive care and treating them with ventilation, doctors need to think about the risk the patient will not be able to breathe on their own again once ventilation is removed. They explained when a patient is on a ventilator, the machine does the work of breathing for them. Over time, their breathing muscles can become weak from not being used. If doctors remove the ventilator and the patient’s breathing muscles are not strong enough, the heart must work much harder. Our intensive care adviser said this can quickly lead to exhaustion and low oxygen levels.
25. The guideline for the Provision of Intensive Care Services says when providing care at the end of a patient’s life, ‘at least two consultants’ should help decide whether to provide or withhold a treatment like ventilation. It recommends each consultant should consider the likely benefits and disadvantages of not providing or of withholding a treatment.
26. We can see two consultants reached a decision that Mrs L was not suitable for admission to ICU by considering her clinical condition and needs on multiple occasions between 10 and 17 November. By 17 November, the consultants reached their view that Mrs L would not benefit from treatment in ICU. They noted she was not showing signs of improvement despite receiving the maximum level of care available.
27. The records show the consultants explained to her family Mrs L was sadly ‘very poorly’ and had a ‘poor prognosis’. They said if they escalated Mrs L to intensive care, she would likely not be able to ‘wean off’ ventilation.
28. We know the family has a specific concern that Mrs L’s blood pressure was low. The Surviving Sepsis Campaign guideline outlines recommendations to help healthcare professionals identify, treat, and manage sepsis and septic shock quickly and effectively. It recommends immediate admission to an intensive care setting for patients with an arterial blood pressure of less than 65mmHg (a measurement of pressure in the arteries).
29. Our intensive care adviser noted although Mrs L’s blood pressure was low during her admission, it responded quickly to treatment. They said at no point was it at a level below 65mmHg. This tells us Mrs L did not require treatment in an intensive care setting specifically to treat her low blood pressure.
30. In summary, we have not seen a failing here. We think the Trust reached its view that Mrs L would not benefit from treatment in an intensive care setting in line with guidance.
31. It was clearly very important to Miss K to know the Trust was doing all it could to treat Mrs L. We hope we have helped to explain that the only additional treatment available to Mrs L in intensive care would have been ventilation, and why this likely would not have been the right thing for her.
Cannula
32. Miss K complains the Trust delayed inserting the CVC. She says doctors were struggling to cannulate Mrs L when they decided to put the CVC in place on 13 November, but they did not successfully put it in place until the evening of 16 November. Miss K says, by this time, Mrs L was unsettled and unresponsive. She says, in their unsuccessful attempts to cannulate her, doctors ruptured Mrs L’s veins and caused her immense suffering.
33. The Trust said the anaesthetist was called on 13 November to insert a cannula as the medical team was having difficulty due to Mrs L’s oedema, which is where fluid gathers in the tissues of the body. It said she was cannulated with a guided ultrasound on 17 November. It said the CVC was discussed with the anaesthesiologist who advised that Mrs L was not a suitable candidate to go to theatre.
34. A CVC is a cannula that doctors place into a large vein, usually in the neck, chest, or groin. It is used to give medications, fluids, or nutrition directly into the bloodstream, especially when treatment needs to be long-term. It can also be used to take blood samples or measure pressures inside the veins near the heart. A patient normally has to go to theatre for the CVC to be inserted.
35. A peripheral venous catheter (PVC) is a cannula that doctors place in a small vein, typically in the arm or hand. It is used for short-term IV access but needs to be replaced around every three days. Doctors can insert a PVC at the patient’s bedside.
36. GMC Good Medical Practice sets out what doctors should do to provide good clinical care. It says when doctors treat patients, they should promptly provide arrange suitable treatment and refer a patient to another practitioner when this serves the patient’s needs.
37. An entry in Mrs L’s records on 10 November shows doctors found it difficult to get ‘IV access’, meaning doctors were struggling to insert a PVC into a suitable vein. Although the entry does not say why doctors were finding it difficult, our physician adviser explained Mrs L’s fluid retention may have made it more complicated to insert the catheter.
38. Our physician adviser said there is evidence Mrs L may have had particularly small and fragile veins because doctors were only successful in cannulating her using the smallest cannulas available. We understand from our adviser it is normal for cannulas to come out when a patient has complications like fluid retention and small veins. Our physician adviser said this is not an indication of a problem with the care a patient is receiving.
39. We understand from our physician adviser that whenever doctors insert a cannula, there is a risk they might rupture the patient’s vein. They said this risk is higher in older people with smaller and more fragile veins. Our physician adviser explained this risk is unavoidable, and doctors need to balance this with the need to administer IV medication.
40. On 13 November, the Trust asked an anaesthetist to assist with putting a cannula in place for Mrs L. Our physician adviser explained it is normal practice for clinicians to ask anaesthetists for assistance with cannulation because they have advanced skills in managing difficult IV access.
41. The records do not say whether the Trust asked the anaesthetist to assist with a PVC or put a CVC in place in theatre at this point. Miss K’s understanding was that the Trust planned for Mrs L to have a CVC line from this date.
42. The records do not show if the anaesthetist attended on 13 November. However, on review with our physician adviser, we can see Mrs L had a PVC in place because she continued to be treated with IV medication.
43. On 16 November, the records show the doctors were having difficulty drawing blood for the blood tests Mrs L needed. We can see doctors asked the Trust’s anaesthetic team to put a CVC in place because, as outlined above, it can remain in the body for much longer than a PVC and can be used to take blood samples. It appears while the doctor was waiting for the anaesthetist to do this, they were successful in getting another PVC in place using guided ultrasound (a procedure where clinicians use images of the inside of the body to guide a catheter into place).
44. The anaesthetist reviewed Mrs L on 17 November. They noted she was ‘not suitable for transfer to theatre’ to have the CVC inserted because she needed an urgent medical review. The records show a doctor was able to insert a new PVC into Mrs L’s arm using guided ultrasound on 18 November. This remained in place until Mrs L’s sad death the following day.
45. We can understand from Miss K’s perspective that Mrs L waited for the CVC between 13 and 17 November. We also recognise her concern that during this time, Mrs L went without IV medication. Although Mrs L did not have a CVC, there is no evidence this prevented doctors from treating her with the medication she needed. The records show she was cannulated and receiving IV medication via a PVC throughout her admission.
46. We are sincerely sorry that the difficulties the doctors encountered when cannulating Mrs L caused her pain and discomfort. Based on the evidence, we think this was sadly unavoidable because Mrs L needed her medication to be administered in this way.
47. We think the doctors acted in line with GMC Good Medical Practice. The evidence we have seen shows they promptly provided Mrs L with the treatment she needed by ensuring she could receive her IV medication via the PVC. When the doctors encountered difficulty cannulating Mrs L, they used guided ultrasound and asked the anaesthetic team for assistance. These actions are in line with Good Medical Practice as referenced above.
48. We have not seen a failing for this part of the complaint. There is no evidence of a delay causing Mrs L to go without her medication. We hope Miss K feels assured by our explanation.
Fluid levels
49. Miss K says the Trust should have done more to monitor Mrs L’s fluid levels, including offering her more scans and tests. She describes it treating Mrs L with ‘bag after bag’ of fluid on 17 November, which she says ‘overfilled’ her. She says the Trust should have stopped treating her with fluid.
50. The Trust said Mrs L needed IV fluids because she had a diagnosis of acute kidney injury. It said the need for IV fluids was also based on her blood results. It said it rectified Mrs L’s fluid overload with a diuretic (a type of medication that helps the body get rid of extra water through increased urination).
51. The NICE BNF gives doctors advice on how to use medicines safely and effectively. It includes information on what medicines do, how to use them, side effects, and when not to use them. It says diuretics, like furosemide, are the main treatment for oedema.
52. Our physician adviser explained Mrs L’s blood test results show she had a condition called hypalbuminaemia. This condition is caused by low protein levels in the blood and is commonly found in a person who is very unwell. When a person has hypalbuminaemia, fluid that should be in the blood vessels can leak out into the surrounding tissues, leading them to suffer from a type of fluid retention called peripheral oedema.
53. Our physician adviser explained peripheral oedema normally gets better as a person recovers from their illness and the protein levels in the blood increase. They said by treating Mrs L’s underlying condition, the Trust was doing all it could to help her recover from peripheral oedema.
54. We know it must have been very distressing for Miss K to feel Mrs L was swollen and uncomfortable and that the Trust was making this worse. Our physician adviser said the fluid retention Mrs L was suffering was not because she had too much fluid in her body. They said the fluid in Mrs L’s body was simply in the wrong place.
55. They explained the records show Mrs L still needed support with her kidneys and may have been dehydrated despite appearing that she was ‘full of fluid’. They said the records show the Trust treated Mrs L with intravenous fluid to keep her hydrated and maintain good blood supply to her kidneys.
56. We understand from our physician adviser there is evidence Mrs L also had fluid in her lungs. This is a condition called pulmonary oedema, and it can happen in a person who is unwell, particularly with an infection which can cause the veins to leak fluid into the lungs. The records show the Trust treated Mrs L with the diuretic furosemide, and we understand from our physician adviser the evidence shows this was intended to help reduce the fluid in Mrs L’s lungs. They said furosemide would not necessarily have helped Mrs L with her peripheral oedema but, as explained, the Trust was treating this by treating Mrs L’s underlying condition.
57. We have not seen a failing here. We think where possible, the Trust was treating Mrs L’s oedema in line with guidance. We realise this was a distressing experience for Miss K, and we hope our explanation has helped clarify things for her.
DNAR
58. Miss K complains the Trust put a DNAR in place for Mrs L without informing her or Mrs L’s next of kin when she was first admitted to hospital.
59. In its complaint response, the Trust said Mrs L’s records show an intensive care doctor discussed the DNAR decision with the family on 17 November. It apologised the family did not feel the full detail of the DNAR decision was explained clearly.
60. Cardiopulmonary resuscitation (CPR) is a series of actions taken in an attempt to revive someone when they collapse with no pulse or breathing (a cardiac arrest). It always involves chest compressions to circulate blood from the heart, and may involve the administration of electric shocks (defibrillation), administration of drugs, and artificial ventilation.
61. The GMC ‘Good Medical Practice: ‘Treatment & care towards the end of life: Cardiopulmonary Resuscitation’ guidance explains that CPR generally has a low success rate. CPR can injure a person’s brain, and cause organ damage and disability. The guidance says if a person is expected to die, doctors should make and record an advance decision not to attempt CPR if they consider it will not be successful. The purpose of this is to make sure the person dies peacefully and with dignity.
62. The GMC guidance outlines how doctors should approach communication with families regarding CPR. It says when making a DNAR decision, doctors must consult with the patient, or, if they lack capacity, those close to them.
63. When Mrs L was first admitted to hospital, on 10 November, the records show a doctor spoke with Mrs L about the likely ‘ceiling’ of treatment (the maximum level of care the Trust could provide to her). The doctor noted Mrs L had ‘poor physiological reserve’, meaning her body had a reduced ability to cope with illness. They noted Mrs L wanted them to speak to her daughter. The doctor noted they had not filled in the DNAR form at this point as they wanted to discuss with Mrs L’s family.
64. The records tell us the doctors discussed the DNAR decision with Mrs L’s daughter (Miss K’s mother) on 12 and 15 November. On 15 November, a doctor noted they had explained to Mrs L’s daughter that Mrs L was unfortunately not showing any ‘signs of improvement’.
65. On 17 November, an entry in Mrs L’s records show Miss K attended a meeting with two consultants, a doctor, and a nurse. The note says Miss K was ‘not happy’ that the DNAR was put in place without informing Mrs L’s next of kin. One of the consultants agreed to speak with Mrs L’s daughter about the DNAR decision.
66. Later that day, the consultant met with Mrs L’s daughter. They noted they explained Mrs L had a ‘very low’ chance of recovery. They also noted they explained why she would likely not survive CPR. Mrs L’s daughter said she was not happy that the decision had been made on 10 November without the doctor informing the family. The consultant apologised for this. We are not clear why the doctor did not explain at the time that the DNAR was not in place on 10 November.
67. The records show a final conversation about DNAR between another consultant and Mrs L’s family. It appears during this conversation the family raised a number of concerns about Mrs L’s care. The notes show the consultant explained how unwell Mrs L was and why there was a DNAR in place.
68. We can see the consultant signed the DNAR form on 17 November, after these conversations took place. Our review of the records confirm it was not in place on 10 November. We think doctors acted in line with GMC guidance because they discussed the decision with Mrs L’s family when making their decision.
69. It is clear there has been some confusion for Miss K about the date the DNAR was in place. We hope we have been able to reassure her the decision was not made without multiple conversations with her and Mrs L’s daughter on 17 November.
70. In light of the above, we do not uphold this complaint. We recognise how Miss K and her family’s life has been affected by Mrs L’s sad death and once again thank her for sharing her experience with us. We hope we have clearly explained how we considered what she told us and the evidence available to us, and how we reached our decision in this case.