15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Sepsis management 16. Mrs B is understandably concerned the Trust missed an opportunity to diagnose and treat her husband for sepsis during his admission in January 2022. She says the Trust gave her husband antibiotics for cellulitis in his right arm and she thinks this was a missed opportunity to treat him for sepsis earlier. She says the cause of his sad death was sepsis and cellulitis and this could have been avoided with different action from the Trust.
17. We were sorry to hear Mrs B’s concerns about how the Trust investigated her husband’s symptoms and managed his care during his admission. From the conversations we had with Mrs B, it is clear this was an extremely difficult time for her and her concerns about the Trust’s actions continue to cause her ongoing distress.
18. NICE guidance on suspected sepsis management says to assess people with any suspected infection to identify factors that increase the risk of sepsis. People who are most vulnerable to sepsis include people that are over 75, those who are frail, severe chronic conditions, impaired immune system because of illness, and breach of skin integrity (disruption to the surface and health of the skin). Mrs B’s husband fits into this risk criteria as he was over 75 and he had an impaired immune system as he had leukaemia and COPD.
19. The guidance says consider using the National Early Warning Score (NEWS) to assess people with suspected sepsis in acute hospital settings. NEWS is a scoring system to identify acutely ill patients or those that are deteriorating.
20. NICE guidance on NEWS says people who score between one and four are at low risk of deteriorating and those with scores between five and six are at medium risk. Our adviser explained the same scores also relate to the risk of severe illness or death from sepsis.
21. RCP guidelines on the NEWS explains how to interpret NEWS, when to escalate a patient’s care, and how often to monitor patients with various scores. The guidelines say patients with a NEWS of between one and four should be monitored four to six hourly and the nurse should assess the patient. The nurse then decides whether to increase the monitoring or escalate the care. A NEWS score of seven or more indicates a need for an emergency response.
22. Our adviser explained that the terms infection and sepsis are used interchangeably. Sepsis is the severe end of the infection spectrum. Signs of severe sepsis would include a deterioration in the NEWS (a high score), a high or low temperature, and hypotension (abnormally low blood pressure).
23. The medical records show the Trust admitted Mrs B’s husband at the beginning of January. Approximately one week later, it assessed Mrs B’s husband and recognised he had a swelling on his right arm. The Trust suspected a skin infection and discussed Mrs B’s husband’s care with a Microbiologist (a scientist in health care) on the same day for advice on how to manage it. The Trust diagnosed the infection as cellulitis which is a skin infection that needs treatment with antibiotics.
24. We have seen evidence the Trust started antibiotic treatment for Mrs B’s husband on the same day it diagnosed him with cellulitis. Mrs B’s husband’s NEWS at this point was between two and three which means he was at low risk of deterioration or severe illness or death from sepsis.
25. Mrs B’s husband’s NEWS was four and below until nine days after his admission. On this date his NEWS was six. This is still below the RCP threshold of seven, but the guidelines say patients with a score of five or more should be monitored again in one hour. We have seen evidence to show the Trust did this and Mrs B’s husband’s NEWS returned to four when it reassessed him an hour later. The Trust resumed monitoring him every four to six hours based on this score, which is in line with the RCP guidance. We have seen no indication it got anything wrong here.
26. As our adviser explained above, a NEWS of five or six suggests a moderate risk of severe illness or death from sepsis. As Mrs B’s husband’s NEWS was four and below (low risk of severe illness or death from sepsis) for the first eight days of his admission, his scores before this did not raise concern for possible sepsis.
27. However, the date his NEWS did increase to six which suggests a moderate risk of severe illness or death from sepsis, we can see the Trust monitored Mrs B’s husband until his score returned to the lower risk level (between one and four). It is important to note that the Trust was already treating Mrs B’s husband for an infection before his NEWS reached six.
28. Our adviser explained that the cellulitis Mrs B’s husband had, is an infection which can be classed as sepsis. However, based on his low NEWS during the beginning of his admission, we cannot see the Trust missed any earlier opportunities to diagnose or treat this and in fact acted before his NEWS reached the threshold suggested by the RCP guidance.
29. Based on the evidence we have seen, it appears the Trust followed NICE guidelines on sepsis when it managed Mrs B’s husband’s cellulitis infection. We cannot see any evidence Mrs B’s husband’s NEWS deteriorated to suggest he was experiencing symptoms of severe sepsis as they remained low leading up to the Trust’s diagnosis of cellulitis.
30. We have seen the Trust diagnosed Mrs B’s husband and began treatment for cellulitis before his NEWS increased to six so we cannot say it missed any earlier opportunities to diagnose and treat his infection. We are also satisfied the Trust monitored Mrs B’s husband in line with RCP guidance when his NEWS increased to six.
31. It is understandable that Mrs B feels the Trust missed an earlier opportunity to treat her husband’s infection. We hope the information we have provided helps to clarify anything she was unsure of and helps to reassure her that the Trust followed relevant guidelines when it managed her husband’s diagnosis of cellulitis.
Blood transfusion 32. Mrs B complains the Trust delayed giving her husband a blood transfusion. She explained her husband’s haemoglobin levels were very low and this should have prompted the Trust to give him a blood transfusion sooner than it did. Haemoglobin is a substance in red blood cells that transport oxygen around the body to help it work.
33. We were sorry to hear Mrs B’s concerns about how the Trust managed her husband’s haemoglobin levels. It is understandable that this was a very worrying time for her.
34. NICE guidance on blood transfusions says use restrictive red blood cell transfusion thresholds for patients who need red blood cell transfusions and who do not have major bleeding, reduced blood flow to the heart, or those who need regular blood transfusions for chronic anaemia. When using a restrictive red blood cell transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion.
35. This means that when the haemoglobin count reaches 70g/litre, a transfusion should be considered. This threshold is relevant to Mrs B’s husband as he did not have major bleeding, reduced blood flow to the heart, or require blood transfusions for chronic anaemia.
36. The guidance also says to monitor the patient's condition and vital signs before, during and after blood transfusions to detect acute transfusion reactions that may need immediate investigation and treatment. Our adviser explained that one of the risks of a blood transfusion is a fever so a transfusion should not take place if the patient has a high temperature.
37. Mrs B’s husband’s haemoglobin levels were above 70g/litre for the first 11 days of his admission. 12 days after the Trust admitted him, they were 70g/litre. His level then fell to 69g/litre following day. These levels of 70g/litre and 69g/litre would trigger the need for a blood transfusion in accordance with the NICE guidance on blood transfusions.
38. We have seen evidence that the Trust considered a blood transfusion when Mrs B’s husband’s haemoglobin level fell below 70g/litre. This action is in line with the NICE guidance on blood transfusions above.
39. However, the medical records show Mrs B’s husband had a fever when his haemoglobin level was 70g/litre. Our adviser explained that although his haemoglobin level on this day would trigger the consideration for a blood transfusion, it would not have been safe for the Trust to proceed with one due to Mrs B’s husband’s fever. Our adviser explained that when his temperature returned to within normal limits two days later, the Trust carried out the blood transfusion.
40. Based on the evidence we have seen, it appears the Trust followed NICE guidance on blood transfusions when it considered a blood transfusion for Mrs B’s husband because of his haemoglobin levels. We can see it delayed giving him this blood transfusion for two days because Mrs B’s husband had a fever and this action is in line with the NICE guidance on blood transfusions which says to monitor the patient’s vital signs before a transfusion.
41. We are satisfied the Trust gave Mrs B’s husband a blood transfusion as soon as it was clinically able to and it did not miss an earlier opportunity to do this. We hope this information helps to reassure Mrs B that the Trust did not unnecessarily delay giving her husband a blood transfusion.
Nebuliser 42. Mrs B complains the Trust gave her husband a nebuliser 13 days after it admitted him, but it did not give him oxygen. A nebuliser is a medical device used to give people medication in the form of a mist which is then inhaled.
43. Mrs B says her husband could not speak as he was so short of breath and eventually got a pulmonary embolism (PE) due to his breathing. A PE is when a blood clot blocks a blood vessel in the lung. She says the Trust also gave her husband steroids in the nebuliser even though too many steroids in his system from his treatment for leukaemia caused his admission in the first place.
44. From our conversations with Mrs B, it is understandable that she is concerned with how the Trust managed her husband’s care before his sad death. We were sorry to hear how her concerns continue to worry her.
45. BNF guidance on inhaled drug delivery explains a nebuliser converts a solution of a drug into an aerosol for inhalation via a face mask or a mouthpiece. It delivers higher doses of drug to the airways than is usual with standard inhalers.
46. Indications of when to use a nebuliser includes the need to deliver ipratropium bromide to a patient with worsening symptoms of asthma or COPD. Ipratropium bromide is a medication used to treat COPD. It works by relaxing the muscles around the airways to open them up and makes breathing easier.
47. NICE guidance on emergency oxygen says people with COPD should have their oxygen levels maintained between 88% and 92%. As Mrs B’s husband had COPD, the guidance from the BNF and NICE guidance on oxygen is relevant to him and his condition.
48. Mrs B’s husband had a feeling of a tight chest 13 days into his admission, so the Trust gave him ipratropium bromide via a nebuliser to help relieve this. This action from the Trust is in line with the BNF guidance above which says to use ipratropium bromide to help treat patients with COPD.
49. It appears Mrs B’s husband’s oxygen levels did not drop below 92% during his admission and this means he did not require oxygen as his levels were above that in the NICE guidance on emergency oxygen. It appears there was no indication for the Trust to use oxygen with the nebuliser because of this. We hope this information helps to reassure Mrs B that the Trust did not miss an opportunity to give her husband oxygen when it gave him a nebuliser.
50. Mrs B is concerned the Trust also gave her husband steroids in the nebuliser. We cannot see any evidence in the medical records to suggest the Trust used a steroid medication in Mrs B’s husband nebuliser. As we explain above, it did use ipratropium bromide, but this is not a steroid.
51. This means we cannot say what happened here or that the Trust got anything wrong as we cannot see any evidence to confirm the Trust gave Mrs B’s husband steroids as Mrs B suspects. We are sorry that we cannot provide any further clarity on this element of Mrs B’s complaint.
52. Based on what we have seen, it appears the Trust followed relevant guidance from the BNF when it gave Mrs B’s husband a nebuliser when he reported symptoms of a tight chest. We can see the Trust gave him the medication he needed to help with this. We have also seen the Trust followed NICE guidance on emergency oxygen when it did not give Mrs B’s husband oxygen with his nebuliser as there were no indications he needed oxygen based on his oxygen levels.
53. We hope our findings and the explanations from our adviser help to reassure Mrs B that the Trust did not withhold oxygen from her husband and we can see no evidence it gave him steroids.
Visiting at the end of life 54. Mrs B is understandably concerned the Trust prevented her from visiting her husband before his sad death because of Covid restrictions. She is concerned the Trust only restricted visiting on the ward her husband was on rather than the whole hospital and she cannot understand why it did not allow her to visit her husband when he was so poorly. She told us how distressing this was for her.
55. During our conversations, Mrs B explained that her and her husband had been married for over 50 years. It is understandable that she found not being able to visit her husband extremely distressing and we are sorry that this was her experience before he sadly died.
56. NICE guidance on end-of-life care says people managing and delivering services should develop systems to identify adults who are likely to be approaching the end of their life. This will enable health and social care practitioners to start discussions about advance care planning, provide the care needed, and to support people's preferences for where they would like to be cared for and die.
57. NICE guidance on multimorbidity says be aware that multimorbidity refers to the presence of two or more long-term health conditions which can affect the quality of life and life expectancy. The conditions include physical conditions such as diabetes, frailty, and chronic pain amongst others. Mrs B’s husband was frail and had a history of leukaemia which our adviser told us would sadly impact his life expectancy.
58. The Trust explained that it made the difficult decision to put visiting restrictions in place because of the increasing transmission rates of Covid at the end of December 2021. It told us it suspended visiting except in exceptional circumstances such as if a patient was receiving end of life care.
59. From the information we have seen, it appears this restriction was in place throughout the Trust, and it asked patients to attend appointments alone where possible. The Trust told us these restrictions were in place during January 2022 when it admitted Mrs B’s husband. We hope this information helps to clarify anything Mrs B was unsure about regarding the visiting restrictions the Trust put in place.
60. As we explained earlier in our report, Mrs B’s husband’s medical records show his NEWS were generally low (below four) during his admission. A NEWS below four suggest a patient is at low risk of deteriorating.
61. We can see the Trust used the NEWS system and observations as tools to monitor Mrs B’s husband as the NICE guidance on end-of-life care says it must. On the day Mrs B’s husband sadly died, his NEWS remained between two and four.
62. Our adviser explained that although Mrs B’s husband was sadly at risk of dying due to his health conditions, his NEWS did not suggest his sad death was imminent. His scores were low on the day of his sad death, and his oxygen levels were 93% and above. With these observations, it would be difficult for the Trust to predict that Mrs B’s husband was about to sadly die. It does not appear the Trust missed an opportunity to recognise he was sadly approaching the end of his life.
63. Based on the evidence we have seen, we are satisfied the Trust did not know Mrs B’s husband’s sad death was imminent. This means we do not consider it missed an opportunity to lift its visiting restrictions to allow Mrs B to visit her husband, in line with its own guidance from December 2021. It appears the Trust followed NICE guidance on end-of-life care when it monitored Mrs B’s husband for signs of deterioration. Having considered the information we have seen, we cannot see any indications the Trust got anything wrong when it managed Mrs B’s husband’s end of life care.
64. We are sorry Mrs B did not get the opportunity to visit her husband before he sadly died due to the visiting restrictions in place at the Trust at the time. It is understandable that this experience has been significantly distressing for Mrs B, and we are sorry she was not able to be with her husband during his final days. We do not underestimate how distressing and upsetting this was for her.
65. Overall, based on the clinical advice and the evidence we have seen, it appears the Trust followed relevant guidelines when it managed Mrs B’s husband’s care in January 2022. It is understandable that Mrs B’s concerns have caused her the ongoing distress she described, and we were sorry to hear how her husband’s sad death impacted her. We hope that our report and explanations go some way to reassure her that the Trust followed relevant guidelines when it managed her husband’s care, and we have seen no indications that anything went wrong.