Ms J’s care and treatment up to the fall
16. Miss B is concerned the Trust did not provide her mother with the right care and treatment following her admission. To date, the Trust has found no issues with Ms J’s care during this time. We have looked at the records to see what happened.
17. Ms J attended A&E with pain in her left knee preventing her from mobilising, worsening shortness of breath and a cough. Her NEWS was 9 on arrival. NEWS is a system used to identify and respond to deterioration. A score of 0-4 is low (ward-based response), 5-6 is medium (key threshold for urgent response) and 7+ is high (urgent or emergency response).
18. The doctor who first saw Ms J noted coarse crackles in both lungs and a widespread wheeze. Coarse crackles often indicate fluid or mucus in the airways usually associated with a chest infection. A wheeze is caused by narrowed airways and can indicate respiratory issues. The Trust’s working diagnosis was infection causing an acute worsening of COPD.
19. NICE guideline 115 says diagnosing exacerbation of COPD is made using a patient’s history and a physical examination rather than by looking at the results of investigations or tests. Considering Ms J’s symptoms, we think the Trust’s working diagnosis at the time was reasonable.
20. We also think the Trust’s management was in line with NICE guideline 115. It says to carry out a chest X-ray, arterial blood gas (ABG), blood tests and electrocardiogram (ECG). An ABG measures the levels of oxygen and carbon dioxide in the blood. An ECG measures the electrical activity of the heart.
21. Ms J had two ABGs and appropriate blood tests. Blood results showed her C-reactive protein (CRP) was elevated at 94 (less than 10 being normal). CRP is a marker for inflammation and can indicate infection. She also had a chest X-ray (her chest was clear) and an ECG, as well as a COVID-19 test.
22. The Trust started Ms J on intravenous (IV) clarithromycin (500mg twice a day). This is an antibiotic used to treat bacterial infections including respiratory infections. The BNF says to give patients with acute exacerbation of COPD or pneumonia (chest infection) this medication and at this dose. The Trust switched to oral clarithromycin the next day.
23. The notes show Ms J also had low blood pressure on admission. The doctor thought her fall was due to a sudden drop in blood pressure caused by infection and dehydration. However, they checked her troponin levels to rule out an acute heart issue. Troponin is a protein, and elevated levels can indicate potential damage to the heart.
24. Ms J’s troponin levels were high at 465 (0-16 being normal). The doctor started treatment for acute coronary syndrome and requested a repeat ECG and troponin test as well as a review by cardiology. Acute coronary syndrome is a sudden reduction of blood flow to part of the heart.
25. Our physician adviser said it was appropriate to treat for acute coronary syndrome at this stage based on Ms J’s pre-existing heart issues and high troponin levels. However, they said inflammation may have caused the elevated troponin levels rather than an acute heart issue.
26. The doctor at the time also noted Ms J had pain in both knees down to the shin. They requested X-rays which she had later that evening (no fractures). This looks to be in line with the GMC professional standards. These say doctors must adequately assess conditions and promptly provide or arrange suitable investigations. Ms J’s NEWS then fell to low overnight.
27. A doctor saw Ms J at 3am on 28 April as her NEWS was 8. Her respiratory rate and heart rate were elevated and her oxygen saturation low. The doctor suspected pulmonary oedema which is where fluid builds up in the lungs making it difficult to breathe. They prescribed furosemide (increases urine output and helps move fluid out of the lungs) and nebulisers (open the airways). Her NEWS then fell to low.
28. Ms J then moved to the acute medical unit. She was seen during ward rounds and later by cardiology. Cardiology stopped treatment for acute coronary syndrome as they felt her high troponin levels were likely due to COVID-19 (her test came later came back negative). Blood tests showed Ms J’s CRP had risen to 112 and her troponin levels had fallen to 344.
29. A doctor saw Ms J that afternoon as her NEWS was 10 due to a rapid and irregular heartbeat. They prescribed bisoprolol (a beta blocker used to treat high blood pressure) to maintain a normal heart rate. This was one of Ms J’s regular medications. Doctors had stopped it due to her low blood pressure. NICE guideline 196 says to offer people with PAF a standard beta blocker to control their heart rate. Ms J’s NEWS then fell to low.
30. Ms J’s NEWS remained low on 29 April. However, she still had a rapid and irregular heartbeat. She also complained of shortness of breath during ward rounds. Doctors said to continue her current treatment for the time being. Repeat blood tests showed her CRP had dropped to 54.
31. Ms J’s NEWS remained low on 30 April until after her fall that evening. Doctors saw her during ward rounds. Her heartbeat was now normal, but she still felt breathless and had reduced air entry on one side. They increased bisoprolol. Blood tests later showed her CRP had increased to 92.
32. Overall, we have found no failings with this part of Ms J’s care and treatment. The Trust’s working diagnosis of infective exacerbation of COPD was reasonable, and it started her on suitable treatment. The Trust then appropriately responded to any worsening of Ms J’s condition.
Ms J’s fall
33. Miss B complains about the circumstances surrounding her mother’s fall. She also says staff gave her conflicting information about whether bed rails were down at the time. To date, the Trust has found no issues with its care here. We have looked at the records to see what happened.
34. Ms J’s records show she was admitted, in part, as she had injured her knee following a fall. The doctor who first reviewed her thought the fall was caused by a drop in blood pressure triggered by infection and dehydration. They noted ‘fall precaution’ as part of their management plan.
35. NICE guideline 161 says older people who present for medical attention because of a fall should be offered a multifactorial falls risk assessment as part of an individualised multifactorial intervention. It says this should include identifying individual risk factors that can be treated, improved or managed.
36. Ms J’s records show the Trust completed an initial falls assessment on 28 April. This found she was at high risk of falls. As she was high risk, nursing staff also completed ‘Falls Prevention Care Plan B’. This is a multifactorial assessment and high risk interventional care plan.
37. This document says the assessment and care plan should be reviewed every 24 hours or if a patient’s condition changes. We have seen no evidence nursing staff completed any further falls assessments for Ms J. Our nursing adviser said this put her at continued risk of falls.
38. We have found the Trust did not follow either its own local guidance or NICE guideline 161 in relation to falls risk assessment. It did not appropriately assess Ms J’s risk meaning it may not have taken appropriate action to help reduce the risk of her sustaining a fall while in hospital.
39. Our nursing adviser said the actions outlined in the Trust’s complaint responses are not sufficient to address the issues with its falls assessment and prevention. They said there is no reference to the education and training needed to improve standards in this area of nursing care. We agree.
40. Nursing staff found Ms J on the floor at 5.30pm on 30 April following an unwitnessed fall. A doctor saw her at 6pm and requested X-rays which they then reviewed at 9pm. They showed she had fractured her femur. The doctor asked the on-call orthopaedic doctor to see her.
41. The on-call orthopaedic doctor saw Ms J at 9.50pm and noted she needed surgery but was visibly short of breath. They asked the medical team to optimise her chest and said she would be seen during orthopaedic ward rounds next day. Ms J’s NEWS remained low that night.
42. We have found the Trust quickly identified the fracture and appropriately sought input from orthopaedics. This looks to be in line with GMC professional standards. These say doctors must promptly provide or arrange suitable advice, investigations or treatment and refer to another practitioner when this serves the patient’s needs.
43. The Trust’s subsequent decision to delay surgery to repair the fracture to allow the medical team to optimise Ms J was in line with NICE guideline 124. This says to identify and treat correctable conditions so that surgery is not delayed by illnesses such as an acute chest infection.
44. We have looked at whether Ms J’s side rails were up at the time of the fall. The ‘inpatient fall review’ completed by the doctor who saw her after the fall says the rails were down and the bed very upright. However, on 1 May, a nurse said they were definitely up, and this information was passed to Miss B.
45. On the balance of probability, it seems more likely Ms J was found with the side rails down as this is what is recorded on the inpatient fall review. This indicates either Ms J, or a member of staff told the doctor the rails were down, or they saw they were down themselves.
46. We can see nursing staff carried out a ‘bed side rail assessment tool’ on 28 April. This asks if the patient uses side rails at home, has a history of falling out of bed, has an altered state of consciousness, has poor sitting balance or has poor spatial awareness. Ms J scored ‘0’ meaning side rails were not needed at that time.
47. Overall, we have found failings in the Trust’s falls risk assessment and prevention as it did not follow its own local guidance or NICE guideline 161. This put Ms J at risk of a fall. We have not found any failings in the way the Trust responded when Ms J suffered a fall on 30 April.
Care and treatment post fall
48. Miss B is concerned the Trust did not provide her mother with the right care and treatment after her condition deteriorated following her fall. She says her mother received no care on the evening of 3 May and nursing staff did not escalate her deteriorating condition to a doctor. She is concerned this directly led, or at least contributed, to her death.
49. The Trust has said Ms J should have been having half hourly observations on the evening of 3 May as her NEWS was high. It also said there is limited evidence of a clear plan to manage this, there was a failure to recognise she was deteriorating and there is no evidence she was considered for palliative care.
50. The Trust said it is unlikely a further medical review by a doctor would have changed Ms J’s treatment or the sad outcome. However, it accepted the family may have been able to spend more time with her had they known she was deteriorating. We have looked at the records to see what happened.
51. Ms J’s NEWS rose to 9 on 1 May and she was seen during orthopaedic ward rounds. They noted she had been consented for surgery but was short of breath. The plan was to proceed with surgery once the medical team had cleared her. She was kept nil by mouth from midnight on 1 May for surgery.
52. Ms J was also seen during the medical team ward rounds. Her NEWS was 8 due to an abnormally fast heart rate and rapid and shallow breathing. They noted a new chest X-ray showed signs of infection. They thought she possibly had hospital acquired pneumonia. Repeat bloods showed her CRP had risen to 110.
53. Later that evening, nursing staff informed the ward doctor Ms J had a high NEWS, and a doctor saw her. They noted there was no evidence of respiratory failure (where the lungs cannot adequately exchange oxygen and carbon dioxide) and referred her to the on-call orthopaedic doctor.
54. At this point, Ms J’s NEWS was high, her CRP was rising again, a chest X-ray showed signs of infection and doctors noted possible hospital acquired pneumonia. Our physician adviser said this was a missed opportunity to seek microbiology advice to ensure her antibiotics covered hospital acquired infection.
55. Ms J’s NEWS fluctuated between 6 and 7 on the morning of 2 May. She was seen during orthopaedic ward rounds. They were awaiting the results of a COVID-19 test and said she should remain nil by mouth for surgery. She then moved to an orthopaedic ward that afternoon.
56. On arrival, nursing staff asked a doctor to see Ms J as her NEWS was 8. This was due to low oxygen saturation, increased respiratory rate and an elevated heart rate. The doctor’s impression was that Ms J had worsening respiratory symptoms secondary to exacerbation of COPD and possibly COVID-19 (a COVID-19 test later came back negative).
57. They spoke with the medical team as they felt she should be under both teams. They asked the medical team to review Ms J and help with her management. They also asked for an anaesthetic review as they were concerned she was not well enough for surgery. They said to continue with her current treatment in the meantime.
58. The medical team saw Ms J shortly after. They noted increased work of breathing, increased respiratory rate and reduced oxygen saturation. They felt her deterioration was likely secondary to infection and fluid overload. This is where too much fluid in the body leads to high blood pressure and shortness of breath.
59. They asked for a repeat chest X-ray, ECG and blood tests. They also said to continue current treatment but consider changing antibiotics if the repeat chest X-ray showed consolidation. This is where air in the small airways of the lungs is replaced with fluid, pus, blood or another material which can indicate issues such as pneumonia.
60. The doctor reviewed Ms J’s blood test results later that day. They noted her CRP had increased from 110 to 157. They said to slow IV fluids until the chest X-ray and to discuss escalating antibiotics. Ms J then had a repeat chest X-ray that evening.
61. The on-call medical registrar saw Ms J later that night. They noted the chest X-ray showed progressive consolidation in the lower area of the right lung and new consolidation in the upper area. They also noted Ms J felt short of breath and was coughing but not clearing her chest.
62. They thought Ms J was clinically dry (not meeting fluid intake targets for her weight) and had community acquired pneumonia. They thought poor positioning was causing her increased respiratory rate, and this was also why she was unable to clear her chest when she coughed.
63. The doctor asked for slow IV fluids, nursing staff to sit her up as much as possible, chest physiotherapy and a review by the medical team during the night. They also added IV teicoplanin to her treatment. This is an antibiotic used in the prevention and treatment of severe bacterial infections.
64. Doctors saw Ms J again later that night. They prescribed furosemide and slow IV fluids and said she should be reviewed again in the morning but remain nil by mouth. We consider there were further missed opportunities here to consider hospital acquired infection and seek advice from microbiology. Ms J was clearly becoming more unwell.
65. Ms J’s NEWS had risen to 7 by 4am on 3 May. Nursing staff asked doctors to see her and a doctor reviewed her at 4.30am. She had an increased respiratory rate and heart rate plus reduced oxygen saturation. Doctors asked nursing staff to administer nebulisers and IV fluids.
66. Ms J’s NEWS remained 7 so nursing staff asked doctors to see her again at 6.50am. A doctor saw her and noted her CRP was now 223. They thought she had worsening infective exacerbation of COPD. They suggested a discussion with microbiology, repeat COVID-19 swab, rapid flu screening and review by the day team. They also said to keep her nil by mouth though they did not think she was fit for surgery.
67. Ms J’s NEWS was 8 at 9am. Nursing staff asked doctors to review her, and they saw her at 10am. They noted she was not speaking in full sentences, had poor respiratory effort, difficulty sitting forward and was still clinically dry. They asked nursing staff to give her IV fluids straight away.
68. Doctors asked nursing staff to switch from oral clarithromycin to IV, start digoxin (used to treat PAF), elevate her lower limbs and get blood cultures. They also said she needed hourly observations and another review by a doctor in four hours. Ms J’s NEWS was then 11 at 11.05am and 10 at 12.04pm.
69. We can see nursing staff asked doctors to see her at 12.05pm and a doctor came to review her. They asked nursing staff to monitor her heart rate using a cardiac monitor for one hour. Her NEWS remained 11 so nursing staff asked doctors to see her again. A doctor then saw Ms J at 3.45pm.
70. Their impression was worsening pneumonia on a background of COPD, and that sepsis was causing her increased heart rate. Sepsis is a life-threatening condition where the body’s response to an infection injures its own tissues and organs. They said to continue IV antibiotics and fluids. They also asked anaesthetics to review her.
71. An anaesthetist saw Ms J at 6pm. They noted some markers for infection had improved but her recent chest X-ray was slightly worse and she was now on four litres of oxygen with an elevated respiratory rate. They suggested a discussion with microbiology as they felt she likely needed to be on a different antibiotic.
72. The anaesthetist also noted her urinary output was low, she was thirsty and had not had much fluid. They advised IV fluids and another review in four hours. They said to continue digoxin, monitor her levels and do a further ECG. They said she was currently high risk with reversible issues.
73. Ms J’s NEWS was 10 at 7.18pm so nursing staff asked doctors to see her again. A doctor saw her at 8.50pm and noted her heart rate had settled with fluids and digoxin. However, she was asking for water and complaining of being thirsty. They asked nursing staff to start slow IV fluids and contact doctors with any concerns.
74. A doctor then saw Ms J at 9.15pm. Her NEWS was 9 and she was asking for water. They asked nursing staff to give slow IV fluids. Their plan also says ‘ward registrar’ though it is unclear if this means she had been seen by them or needed to be seen by them. Ms J’s NEWS then remained high. It was 11 at 11.31pm, 8 at 1.05am, 8 at 2.07am and 10 at 3.04am.
75. The next entry in the notes is by a nurse at 5.20pm. This says ‘continue on high NEWS calls. Doctor aware’ and ‘NEWS 10 red NEWS call placed’. Ms J’s NEWS was still 10 at 5.25am. There is then a doctor’s note at 5.30am. It says they reviewed Ms J after noticing her blood pressure was very low.
76. The doctor noted nursing staff had contacted orthopaedics and not the medical team. They said Ms J was on oxygen but gasping for breath and the machines could not measure her pulse or oxygen saturations. They informed a more senior doctor and started IV fluids, but Ms J very sadly died shortly after this.
77. NICE guideline 50 says patients should have a clear written monitoring plan specifying which physiological observations should be recorded and how often. Our physician adviser said the plan the doctor made at 9.15pm did not include any details on the frequency of monitoring/observation or which observations need to be monitored.
78. The NEWS guidance says a high NEWS is a key trigger threshold and should prompt emergency assessment by a clinical team and usually transfer of the patient to a higher dependency care area. It also recommends continuous monitoring and recording of vital signs. Ms J’s care was not in line with this guidance on 3 May.
79. Ms J’s NEWS rose to 7 at 3.59am, 8 at 8.59am and 11 at 11.05am. It then fluctuated between 8 and 11 up until her death. Despite this, she was not continuously monitored, and they were times when nursing staff did not record her observations for long periods, such as between 3.18pm and 7.18pm.
80. The records also suggest nursing staff recorded Ms J’s high NEWS throughout the night on 3 May but did not seek input from doctors until 5.20am. There is also no other nursing documentation from that night. Our nursing adviser said Ms J’s observations showed she was deteriorating yet the records give no sense of urgency.
81. The NMC professional standards say nurses must make sure any treatment, assistance or care for which they are responsible is delivered without undue delay. They say nurses must respect the skills, expertise and contributions of their colleagues, referring matters to them when appropriate.
82. The NMC professional standards also say nurses must identify any risks or problems that have arisen, and the steps taken to deal with them so that colleagues who use the records have all the information they need. Ms J’s nursing care on 3 May did not meet these standards.
83. Our nursing adviser said a failure to maintain accurate nursing documentation will lead to gaps in patient care and failure to action appropriate treatment. This could cause serious harm to patients. They also thought the service improvements the Trust had outlined in its complaint responses were inadequate. We agree.
84. The Trust has not set out how it will educate and develop nursing staff to improve their competencies. It has also not given timelines for this work or set out how it will check whether it has made appropriate improvements in nursing care. Our nursing adviser also said the Trust needs to revise its policies and care pathways.
85. Our physician adviser said the Trust should have also considered referring Ms J to palliative care for their input. This is because she was at the ceiling of the care and treatment she could receive and was not responding. This would have been in line with GMC professional standards which say doctors must refer a patient to another suitably qualified practitioner when this serves their needs.
86. Overall, we have found the Trust delayed in seeking advice from microbiology to ensure Ms J was receiving appropriate antibiotics and failed to refer her for palliative input. This was not in line with GMC professional standards or NICE guideline 124. We have also found Ms J’s nursing care on 3 May was very poor. It was not in line with NEWS guidance or the NMC professional standards.
Communication
87. Miss B complains the Trust failed to keep the family informed of her mother’s condition. She says this added to their distress. We have looked at the records to see what happened.
88. A doctor spoke with Ms J’s husband at 4.30pm on 30 April. The notes say they explained she was being treated for an infective exacerbation of COPD and was stable. It also says they had treated her for a fast heart rate which was improving.
89. A nurse then spoke with Miss B at 11pm following Ms J’s fall. Miss B was already aware of the fall but had concerns about what happened. The note says the nurse told her Ms J needed surgery which would happen the following day or the day after.
90. A nurse then spoke with Miss B about the circumstances around the fall at 9am on 1 May. There is a note of a call between a doctor and Miss B at 4.30pm. The notes say the doctor explained the on-call doctor saw Ms J after the fall and arranged X-rays which showed the fracture. They apologised for the fall and injury.
91. They also discussed the plan for surgery the following day. However, the doctor said they were concerned about Ms J’s chest infection, and they would need to keep this under review to make sure she could have the surgery. The notes say Miss B asked to be contacted with any updates.
92. Miss B then spoke with a nurse at 11.40am on 2 May. The note says she spoke with her mother using the ward’s telephone. It also says nursing staff updated her on her mother’s condition. The next note is by a nurse at 12.05pm on 3 May. It says Miss B had asked to be told about any deterioration.
93. As set out above in paragraphs 48-85, the records show Ms J’s condition started to deteriorate on 1 May. This should have triggered a conversation with Ms J and her family to take place. This was needed to discuss the seriousness of her illness and the potential she may not recover.
94. Ms J then continued to be unwell up until the time of her death. This means there were further missed opportunities for doctors to speak with her and her family during this time. This would have allowed Ms J and her family to be better prepared for what happened and make informed decisions about what to do.
95. Overall, the Trust’s communication was not in line with GMC professional standards. These says doctors must give patients the information they want or need to know in a way they understand. They also say doctors must be considerate to those close the patient and be sensitive and responsive in giving them information and support.
96. We recognise Ms J’s admission was early during the COVID-19 pandemic. We know the NHS was under incredible pressure at the time, and the situation was often uncertain. However, we consider the Trust’s communication was so poor it amounts to a failing.
Complaint handling
97. Miss B is unhappy about the time the Trust took to respond to her complaint. She says it took around 18 months to provide one response. She also says it did not identify any failings in her mother’s care until she raised specific concerns after going through the clinical records herself.
98. We have found issues with complaint handling started when Miss B raised further questions on 10 January 2022 after going through her mother’s records. The Trust initially answered Miss B’s questions. However, when she raised further questions on 19 January 2022, it said it would do a review and let her know ‘if anything comes of it’.
99. The NHS Complaint Regulations say NHS organisations should investigate complaints speedily and keep complainants informed as far as reasonably practicable. They also say NHS organisations should respond to complaints within six months, notify complainants in writing if this is not possible and respond as soon as reasonably practicable.
100. The Trust’s response on 31 January 2022 was clearly not in line with the NHS Complaint Regulations. It left Miss B not knowing if she would ever hear about her complaint again. This is unacceptable. After some time passed, she understandably thought the Trust’s review had not led to anything.
101. However, Miss B then received a report from the Trust on 2 August 2023, some 18 months after its last contact with her. This review highlighted a number of issues with her mother’s care shortly before her death. This must have been very upsetting for Miss B to receive out of the blue.
102. Overall, we have found the Trust’s complaint handling was so poor it amounts to a failing. It gave Miss B no indication if or when she might receive a complaint response, did not contact her again for 18 months and then sent a report outlining issues with her mother’s care unannounced.
Impact of failings
103. Miss B is concerned poor care and treatment directly led, or at least contributed, to her mother’s death. She has told us the lack of communication meant the family were not prepared for what happened, and they were denied the opportunity to spend her final hours in the way they would have wished. Miss B says this has had a lasting emotional and psychological impact on the family.
104. We cannot say the Trust could have prevented Ms J’s fall had the failings we have found not happened. However, we recognise our findings will cause Miss B and her family distress. It may also leave them wondering what might have happened had the Trust better assessed and managed the falls risk. We do not underestimate the upset this can cause.
105. Ms J had medical problems prior to admission, was frail and had not mobilised whilst in hospital. Her husband also told doctors he would need extra help when she was discharged. If she had recovered from her initial illness, it seems very likely she would have needed some time in hospital to receive physiotherapy and arrange a package of care at home.
106. Our physician adviser said people with existing conditions who have extended time in hospital are at increased risk of developing hospital acquired infections. Ms J had been in hospital for more than 48 hours, blood tests showed worsening infection markers and a chest X-ray also showed her condition was worsening.
107. Blood cultures taken on 3 May identified klebsiella pneumoniae. This is a bacteria found in the environment and human intestinal tract. It can cause a range of healthcare associated infections including pneumonia. It seems very likely Ms J developed a hospital acquired infection as doctors first suspected on 1 May.
108. It is difficult to say what might have happened had doctors sought microbiology advice sooner or changed antibiotics. We cannot say, even on the balance of probabilities, that the Trust missed an opportunity to prevent Ms J’s death. However, we recognise our findings will cause Miss B and her family distress.
109. Our physician adviser said if a doctor had seen Ms J sooner on the night of 3 May, they might have tried more aggressive fluids or changed antibiotics. However, they thought it was unlikely this would have changed the outcome given the speed of Ms J’s deterioration and the fact she had already been very unwell for nearly 36 hours.
110. A referral to palliative care would have led to better planning around what to do in response to further deterioration and meant Ms J’s final days or hours could have been more comfortable. We note she was kept nil by mouth from midnight on 1 May and had been asking for a drink.
111. Ms J’s family would have been better prepared for what happened had the Trust’s communication been better. They may have also been able to spend more time with her before she died. A referral to palliative care would have supported communication with Ms J and her family and helped them prepare for any deterioration.
112. Miss B has told us the uncertainty and long delays in the Trust’s complaint handling significantly prolonged the family’s grief and prevented them from finding closure. She says her and her family have suffered with the effects of these events for almost six years.
113. We consider the Trust’s poor complaint handling added to Miss B and her family’s distress. We recognise how upsetting it is to question whether something went wrong with a loved one’s care and be left wondering what might have happened had things been different.